Volunteers and responsibility for risk-taking: Changing interpretations of the Charter of Médecins Sans Frontières

Abstract

The Charter of Médecins Sans Frontières (MSF), the guiding document for all of the organization's members, states in the final paragraph that volunteers “understand the risks and dangers of the missions they carry out”. Through a review of the different periods in the history of MSF, this article analyzes the changing interpretations that the organization's successive leaders have given to this reference to the acceptance of risk by individuals. The professionalization and expansion of MSF, coupled with its diversifying volunteer base and the changing international environment, have required constant renegotiation of the balance between institutional and individual responsibility for the dangers faced in the field. No doubt this process is far from over.

Unlike the International Committee of the Red Cross (ICRC), the organization Médecins Sans Frontières (Doctors Without Borders, MSF) has no formal mandate – it has not been commissioned by States or other institutions to carry out humanitarian action – and instead bases its work on the principles enshrined in its Charter.¹ The MSF Charter refers to the three “Dunantist” principles of neutrality, impartiality and independence shared with the International Red Cross and Red Crescent Movement, but it is in the name of “universal medical ethics and the right to humanitarian assistance” and with respect for their “professional code of ethics” that the organization's volunteers claim “full and unhindered freedom in the exercise of their function”.² The legitimacy of MSF's humanitarian action was originally derived less from international humanitarian law (IHL) than from the affirmation of medical care as a universal right and from a politico-philosophical engagement. In the Cold War years, when the organization was founded, the symbolic figure of the sans frontières doctor probably owed less to the Geneva Conventions than to the position held by Albert Camus, who refused to choose between two murderous ideologies and proposed that we should “at least save human lives, so as to ensure the future”.³ But it is the final paragraph of the Charter that deserves particular attention: “As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them.”⁴

The MSF Charter is the document that cements the collective identity of the organization and its members. As asserted in all the intersectional agreements adopted throughout the history of the MSF movement, the Charter is the basic document to which all its national sections⁵ commit themselves to adhere. All the volunteers sent into the field to take part in operations are also bound by the Charter. However, several decades after it was drafted, the ethical and legal value of the final paragraph of the document is not beyond question. At a time when there is deep concern across the international humanitarian movement about threats perceived to be of an unprecedented scale and nature, and when legal and technical rules borrowed from the private for-profit sector, notably the duty of care, are increasingly influencing employment relationships and institutional responsibilities in the aid sector,⁶ what does the text of the MSF Charter actually mean in practical terms with regard to responsibility for risk-taking? Is it still a relevant guide for the organization's work?

Rony Brauman observed in a past edition of this journal that the commonly held idea that MSF was created in opposition to the ICRC's commitment to remain silent is something of a founding myth written in retrospect.⁷ Another little-known part of MSF's history is that some of the founders, despairing of ever being able to establish an independently operating organization, had resolved, three years after it was created, to make MSF a recruitment platform that would provide existing aid agencies with health-care volunteers, ensuring that their work received media attention.⁸ For more than a decade, the leaders of the organization talked more about the Médecins Sans Frontières than about MSF the organization. Although the Charter defined the collective ethos that united these committed professionals, the final paragraph of the text and its implementation in operational terms – taking into account that the material and logistical support that the organization could provide for its volunteers was, in practice, extremely limited – required of each of them an individual commitment and seemed to value a spirit of selflessness and vocation, only heightened by the reference to potential dangers. The original text of the Charter lent itself to this interpretation, as the Doctors Without Borders were presented as “anonymous” and unpaid (“bénévole”) and expecting “no personal or collective reward from their work”.⁹

The emphasis that the authors of the Charter apparently placed on individual choice and responsibility was never formally abandoned. Yet, by breaking away from the vision of the founders at the end of the 1970s and setting in motion the progressive development of an organization equipped with the human, logistical and financial resources required to implement independent relief activities, the generation that carried on the MSF project was in effect making volunteers increasingly reliant on institutional and hierarchical mechanisms. This entailed a sharing of responsibilities in terms of risk-taking and security, which has been subject to constant renegotiation ever since. The growth of the organization itself has continued to provoke opposing positions on the question of dangers faced in the field: on the one hand, security issues and threat assessment were seen to justify acquiring more resources, professional skills and procedures, while on the other, it was argued that uncontrolled growth would pose new risks for volunteers.

The very concept of volunteering has been another issue that has remained open to debate. In 1991, the five sections founded over the previous two decades agreed to revise the text of the Charter, and it was in this revised text that the final paragraph introduced the word “volontaire”/“volunteer”. The amendment did not, however, add anything in terms of status or specific legal content to the concept. In France, there is a legal definition of the term “volontaire”,¹⁰ which distinguishes it from “salaried employee” as well as “bénévole” (a bénévole receives no monetary compensation, while a volontaire receives an allowance), but this is not the case in all the countries with MSF national sections. The move to introduce a salaried status for some expatriate positions in the field did not preclude either that these employees continued to be referred to as “volunteers” in the organization's discourse. In effect, the “volunteers” referred to in the Charter soon came to mean all professionals who engage with the organization's work by joining its teams in the field. By so doing, they were becoming members of the MSF organization, which, up until the early 2000s, differentiated them from national staff. From then on, the issue of the geographic origin of MSF volunteers, previously of mainly Western origin, and the dividing line between expatriates and “national” staff would become the subject of debate and, later, reforms which are still in progress today. The profile of the MSF volunteer has thus evolved. However, in the numerous debates that have punctuated the history of the organization, whether to praise or to limit individual risk-taking has remained a pending issue.

While the work of sociologists such as Pascal Dauvin and Johanna Siméant focuses on the evolution in the motivations of humanitarian volunteers,¹¹ the authors of this article aim to analyze the changing interpretations given to the MSF Charter and its reference to the individual acceptance of risk by volunteers throughout the history of the organization, from the point of view of the institution through the discourse of some of its representatives.¹² This account, which does not claim to be exhaustive, is divided into three periods, which have been called the “time of adventure”, the “time of concern” and the “time of terror”, based on the changing outlook of key players and the prevailing geopolitical factors. The aim is to show the persistence of certain dilemmas and major ethical and political questions, to which the profound changes occurring in the organization and in the world in general make it necessary to find new, yet always momentary, answers.

The time of adventure

During the first decade of MSF operations and even beyond that time, the dangers faced by volunteers in the field were highly romanticized. The organization's first spokespersons saw them as a matter of “destiny”, the inevitable “price to pay”, the necessary trade-off for the boldness of the volunteers’ mission.¹³ Under this vision, the Charter appeared largely sacrosanct as the founding document; it not only founded the organization and established a “duty”¹⁴ that its members were to fulfil, primarily in dangerous situations, but also initiated a unique, pioneering venture, which would inevitably be met with hostility and suspicion by a world that was not ready for the enlightened “reason” embodied by the Doctors Without Borders. “In this world, neutrality is always suspect … we have not been able to avoid the insinuations, the murmurs of disapproval, the misinterpretations”, remarked MSF's charismatic founder Bernard Kouchner in 1977.¹⁵ Three years later, when the first volunteer to be injured by gunfire was brought back from Chad, Xavier Emmanuelli¹⁶ observed that it was inevitable “that there should be combatants who are suspicious of us because we want to care for the weak and the abandoned, that there should be armed men gone mad to aim at our doctors and shoot them – for no reason”.¹⁷ There were, however, some reasons, of which the organization was not unaware: the actions of the French army, which was a strategic ally of Hissen Habré, the president of Chad, clearly contributed to “the mistrust shown by the armed opposition group towards Europeans and the French in particular”.¹⁸ The small MSF medical team that had been working with the ICRC quickly resigned itself to withdrawing – possibly at the request of the ICRC? team itself – in order “to avoid putting the Swiss teams at greater risk”.¹⁹

Emphatic though it was, the discourse of the time did not therefore rule out the recognition of limitations on medical assistance or the adoption of measures to try to reduce the risks. Exploratory missions constituted the first such measure and indeed the first boundary for the exercise of individual judgement and free choice by volunteers. While asserting that “nothing great is achieved, nothing is built … without taking risks”,²⁰ Francis Charon, president of the French section from 1980 to 1982, urged volunteers to exercise caution and a degree of discipline: “respect the guidelines proposed by exploratory missions. We are not expected to be heroes, we are asked to do our work as best we can, as warm-heartedly as possible, and above all to come back alive.”²¹ It is in fact not uncommon for exploratory missions or contacts with belligerents, sometimes on the initiative of the latter, to result in the decision not to send volunteers or to suspend relief operations. This was the case in Honduras, in 1980, when MSF refused to meet demands made by Farabundo Martí National Liberation Front (FMLN) guerrillas to send them a surgical team. Both ethical and security reasons were put forward to justify the refusal. As the FMLN did not control any territory in Honduras, MSF leaders considered that if they complied with the request, the volunteers would become “guerrilla doctors”, exclusively serving the armed group, which would expose them to attacks from anti-communist paramilitary groups in Honduras.²² The first mission to Afghanistan was also interrupted in the same year, because the Afghan contacts on which the operation depended were deemed unreliable. According to the head of mission, the demands for money made by the Mujahideen to escort the MSF teams “bordered on extortion”.²³

Added to this initial clash between the call for caution and the spirit of adventure, which continued unabated during the 1980s, was the tension inherited from the dispute that prompted Bernard Kouchner and most of the founders to leave the organization in 1979. Under its new leadership, MSF increased its human and technical resources. These measures were meant to professionalize the organization, but were also justified in the name of security: field coordinator positions became increasingly common, and so did the new means of communication for which they are responsible – “radios and walkie-talkies in Somalia and Honduras, planes in Uganda and telephones in Zimbabwe reinforce security”.²⁴ These new resources evidently restricted the volunteers’ autonomy, and the organization's new management felt compelled to defend itself from the “Kouchnerian” criticism that it was becoming overly bureaucratic: “Are [these innovations] necessary or do they weigh down the machinery of MSF? We believe that they are essential; we should no longer leave large or dispersed teams alone in these dangerous countries without any contact with France”.²⁵ Although this issue was provisionally resolved in the 1980s, it has since resurfaced again and again in the wake of institutional growth and the creation of new national sections within the MSF movement.

Parallel efforts focused on winning over public opinion as a means of controlling the risks run by MSF teams. The new means acquired by the organization also contributed to this goal: opinion campaigns to secure the release of imprisoned volunteers and to denounce the Red Army bombings of field hospitals set up by Western NGOs in Afghanistan required new logistics, telecommunications and mobilization resources. These campaigns, in particular the one launched jointly with Médecins du Monde and Aide Médicale Internationale for the release of Dr Augoyard, jailed in Afghanistan for six months, led Rony Brauman, then president of the French section, to conclude in 1984 that “the support of public opinion [is] our only real protection”.²⁶ The campaigns also gave the three NGOs, the so-called French Doctors, the idea of drafting a “charter for the protection of the medical mission” for States and intergovernmental organizations to sign, again relying on the pressure of public opinion.²⁷ This reflects the other main trend in this era, whereby MSF leaders regarded their work not as an effort to implement IHL but as an extension of it, a struggle to have new rights recognized. As Brauman put it, while accepting the risks of war is an integral part of the organization's mission,

part of these risks are due to the non-recognition, at the international level, of humanitarian action [carried out by foreign organizations in undeclared conflicts]. What is at stake there, the right to humanitarian assistance, the right to care, is in any case worth fighting for.²⁸

Contrary to the common perception that the 1980s were the final years of the golden age of humanitarian action, MSF members saw this decade as a time when they were struggling toward progress – that is, recognition for their cause, which should lead to improved security conditions for volunteers in the field. Although the above-mentioned joint project for a charter was promptly shelved, progress seemed to be made as the organization's reputation continued to grow, with bravery shown in action in the field closely linked to the courage shown in bearing witness and speaking out.²⁹ As Brauman proclaimed in 1987:

Our work in the field is at the core of the highly positive image we enjoy … and the difficulties arising from often sensitive environments give it a sense of adventure. However, our role as agitators, as exposers of closed-door massacres massacres, remains a critical part of our work.³⁰

An example of this was the successful resolution of the abduction of an MSF team on the Somali border by an opposition group, which was largely attributed to the positive public image that MSF had achieved.³¹ Hence, the string of killings that left three MSF volunteers dead in Sudan in 1989 and in Afghanistan the year after were not seen as marking the end of an era, in spite of the evident shock sparked by these first fatal attacks. They were, rather, a tragic confirmation that the absence of targeted fatalities in previous years was largely due to “luck” and the “miracles” constantly referred to in the President's Reports. Following the killings, Dr Olivier Strasser, president of the Swiss section of MSF (founded in 1981), observed:

Our vocation to provide medical assistance to civilian populations takes us to conflict areas where the safety of our volunteers is dependent on safeguards granted by the combatants. As a general rule, humanitarian assistance is respected. We must do everything in our power to ensure that this situation does not deteriorate and that recognition of the right of civilian populations at risk to receive assistance is spread throughout the world. To promote this right and denounce, in extreme cases, obstacles preventing it from being exercised is not the least of our organization's roles.³²

The time of concern

The understanding of MSF's role as a necessary denouncer of obstacles preventing populations’ right to receive assistance was definitely put to the test in the 1990s. As a consequence, some new operational modus operandi have been developed and the institutional structure has adapted, again bringing into question where the responsibilities lie – from the organization, including the associative part, to the volunteers – and indeed the very definition and understanding of volunteerism.

New compromises

At the 1990 MSF France General Assembly, held after the first violent volunteer deaths, the French section reaffirmed its commitment to war missions, defending them as a “foundational and fundamental characteristic of MSF”.³³ However, a debate arose on how best to adapt operational models to these more dangerous contexts. The outcome was a series of proposals, falling short of establishing new standards and essentially leaving the debate open:

[M]ore streamlined, periodic missions, where appropriate, exclusively curative objectives, highly detailed briefings and regular visits to assess the security environment by people not directly involved in the programme, preferably members of the Board, are some of the main points that have emerged from the debate so far.³⁴

The debate also prompted a rethinking of the sharing of responsibilities with regard to risk assessment and decision-making. Here also, it was a pragmatic approach that Brauman defended, taking into account the psychological conditions of volunteers in the field:

Although we all know that trivialization of a situation is one of the worst enemies of security, we are also well aware that it is, to a certain extent, essential to maintaining a mission; you cannot live and work while facing constant threats everywhere.³⁵

Following on from this and confirming the collective, but also potentially conflictive, nature of risk assessment, Brauman concluded that “it is by combining and contrasting points of view from the field and from HQ that we can piece together our responses and, when discrepancies arise, arbitral decisions will always err on the side of caution”.³⁶ However, these attempts to find a middle ground soon ran into difficulties, because with the multiplication of what would be called “extreme crises”³⁷ in the following years, even the path of caution led to dilemmas that were difficult to resolve.

The end of the Cold War and the conflicts that broke out in the early 1990s forced MSF to reconsider the limits of its action. To begin with, however, this did not seem to be interpreted as constituting a fundamental break with the volunteers’ past experiences, although it did oblige the organization to find new compromises and new positions. In Croatia, in the Battle of Vukovar, the explosion of a mine targeting an MSF convoy, in which two nurses belonging to the Swiss and French sections were seriously wounded, “revived”, according to the president of MSF Switzerland, Olivier Strasser, “the debate on how to protect our teams in situations in which even negotiation with all the parties to the conflict does not guarantee protection”.³⁸ In Somalia, an unprecedented solution was found to deal with the problem: the use of paid armed guards was negotiated with the warring factions. According to the president of MSF France, “this solution pose[d] a serious problem of principle”³⁹ and was considered to be a compromise both temporary and unsatisfactory, even when compared with past reliance by field teams on Afghan Mujahideen groups or UNITA forces for their protection in the course of the previous decade. At the same time, the offensive nature of UN-mandated troops, particularly when led by Western forces, as in the case of Operation Restore Hope in Somalia, was beginning to raise concerns about the blurring of the lines between military and humanitarian action. This evolution prompted the French section to recruit an IHL expert and take this body of law into account in a much more systematic and rigorous manner than in the past in reminding these combatants about their responsibilities, although they were then much more focused on the “protection of civilian populations” than on the dangers to aid workers.⁴⁰

These new developments and challenges did not stop Brauman from voicing his scepticism, in 1993, about

the rather vague statements concerning the closure of the world, a new international context in which humanitarian action would become more and more difficult and less and less accepted. Comments about revival of identity, nationalist tensions, the rise of religious fundamentalism are bandied about. They are all real factors, but nobody has been able to prove, taking into account the importance of humanitarian action seen in the field, that these are insurmountable obstacles.⁴¹

Experiencing large-scale massacres and targeted attacks

The experience of MSF teams on the ground in Rwanda at the time of the genocide of the Rwandan Tutsi in 1994 was of a different nature.⁴² Up until the massacres began, following the assassination of the Rwandan president on 6 April 1994, the volunteers had not anticipated or understood the full implications of the political situation in the country, which they regarded as a civil war mainly affecting neighbouring Burundi. It was, in fact, Burundian refugees in Rwanda who were the first beneficiaries of MSF's medical assistance. As the violence swept through the country, the teams were evacuated one after another. Almost always, they had to leave behind their Rwandan colleagues, who were mostly Tutsi, and many of whom were subsequently killed in the massacre. It was therefore a bitter observation that Philippe Biberson, the new president of MSF France, made a year later: “This failure to understand the situation and the hasty departure of our field teams brings to light our lack of preparation for the worst, which meant that we had to abandon our Rwandan staff in tragic circumstances.”⁴³ There is no shortage of examples of individuals taking risks in this tragic episode to care for or protect patients or colleagues, but most of these efforts were in vain. A notable exception, although with limited effect, was the medical and surgical team of six volunteers which managed to set up again in Kigali in mid-April and continued to provide assistance under the banner of the ICRC until the capital was taken by the opposition army, the Rwandan Patriotic Front.⁴⁴

Besides the lasting trauma that these events caused among the different sections of the MSF movement, the extreme violence perpetrated during the Rwandan genocide was to have repercussions in the Great Lakes region too, including, in some cases, targeted attacks against humanitarian organizations. Burundi was an emblematic case, with at least 17 expatriates killed in the period between 1994 and 1996, including three delegates of the ICRC. At the same time, the conflicts in Liberia, Sierra Leone and, to an even greater extent, Chechnya, where the mixture of criminal and political violence resulted in an escalation of killings and kidnappings, intensified and increased exposure to risks for members of the organization to an unprecedented level. In 1995, this situation gave rise to a new debate on the issue of responsibility, which attested to the growing complexity of decision-making mechanisms. As programme managers (PMs) at headquarters were able to maintain more regular contact with teams in the field, thanks to the increasing speed of telecommunications, their responsibility for risk-taking increased. At a Board meeting at MSF France HQ, PMs referred to the “unhealthy pressure” arising from a sense of “‘duty’ to stay in place at all costs”.⁴⁵ They also highlighted a growing contradiction in their functions, which they summarized as follows:

The PM informs the expatriate of the risk of attack and the safety measures he or she should take. Coordinators [in the field], while ready to take risks themselves, are reluctant to risk the lives of their teams. The PM [must therefore] advise them and encourage them to take risks.⁴⁶

They thus asked the Board members to provide a clear position on this matter: “It is up to MSF to place limits on the risks to be taken”.⁴⁷ The Board based its response on the fact that “risk is mentioned in the MSF Charter”.⁴⁸ There was no mention in this statement of volunteers on the ground having the primary responsibility for assessing risk. On the contrary, the Board members considered that, so long as the assessment is made by the operations department and its conclusions shared, “the association bears collective responsibility”.⁴⁹ Over the following years, the Board was repeatedly requested to clarify the organization's position on sending teams to particularly dangerous areas or on maintaining them in such places.

The aid world under question

Concern expressed during this period was due not only to dangerous contexts, but also to developments within the aid world that were increasingly identified as risk factors. Philippe Biberson, president of the French section from 1994 to 2000, reiterated this warning with increasing emphasis throughout his term in office. In relation to the MSF operation in Chechnya, he lamented that “the tendency to design our response based on the range of resources at our disposal” rather than on context-specific considerations “has put us in a straightjacket, which constrains us and makes us vulnerable because we are too visible and have too much to lose”.⁵⁰ The following year, after humanitarian agencies had been repeatedly looted in Liberia, he condemned the “vain displays of power” and the “disparate intentions” of the aid world.⁵¹ At the MSF France General Assembly in 1997, he observed that “humanitarian missions have always been dangerous, but the multiplication of obstacles to aid [and] instances of intimidation, attacks, killings, raids, expulsions and hostage-taking affecting aid workers is a phenomenon that seems to be escalating”.⁵² The risks associated with war and crime are not new; it is the “political targeting” that, while not unknown in the past, “is particularly troubling today”.⁵³ Biberson also pointed to the increasingly crowded humanitarian landscape, with the multiplication of organizations and volunteers carrying out increasingly large-scale activities, many in the midst of conflicts, rather than on the periphery as in the past. In his view, the increase in the dangers faced in the field was due both to political factors, such as “imitative behaviour by organizations [and] standardization and assimilation of NGOs to States or international institutions”, and to economic factors, with “the sheer size of programmes being a contributing factor that exacerbates the problems and risks”.⁵⁴ He also stressed the fact that deteriorating security conditions often stem from a decline in protection of and respect for the civilian population: “in the Great Lakes region, in Chechnya, when there are victims from humanitarian organizations, there are thousands of deaths among the civilian population too”.⁵⁵

While there is a link between violence against aid workers and violence against the people they are trying to help, the technical, ethical and political options put forward to address these concerns may clash. In 1997, the French section opposed the veto imposed by other MSF sections, in the name of the security of their teams, on the publication of articles bearing witness to the systematic massacre of Rwandan refugees in eastern Zaire.⁵⁶ Operations managers and the members of the Board in Paris affirmed that “an approach seeking to defend civilian populations in danger takes absolute precedence over approaches seeking international coherence, internal functioning and ‘team safety’”. They were willing to agree to a “security warning” being issued to give volunteers twenty-four hours’ notice, but refused to be bound by a veto on speaking out on the subject.⁵⁷ A year later, Philippe Biberson voiced a new criticism concerning the problems caused by the security argument:

After the aid workers’ “blues”, it's the security of aid workers that has become the new popular topic! Some organizations offer security training for their volunteers (can they still be called volunteers?) on what to do if they are taken hostage. This training is provided by security experts recruited from among retired army personnel …. The concept of humanitarian space is mishandled to the point that it becomes nothing more than an entrenched camp for humanitarians! It is often the image that we convey that makes us a target.⁵⁸

It is worth questioning the implicit nostalgia evoked by this identity crisis, which identified in the emergence of a “humanitarianism with many different faces” the probable cause of a “loss of respect from the civilian populations”.⁵⁹ As we have seen, MSF volunteers in the early years of the organization were not always welcomed. However, the “misinterpretations” about them were seen to come not from the “civilian populations”, but from armed groups, States or isolated individuals “gone mad”, tied up in logics of political calculation, ideological dogmatism or ignorance against all “reason”. Though they imagined that they were breaking with the past, notably with a long history of colonial and missionary medicine, the spokespersons of the first sans frontières doctors displayed little insight: no potential tension or power imbalances were envisioned in the relationship between humanitarian doctors and their patients. Instead, the practice of MSF doctors, naturally on the side of “oppressed peoples”⁶⁰ and often prone to the same perils that those peoples faced,⁶¹ could only be at odds with the world's oppressors. Even the reference to the “complex ‘Western doctor–Afghan patient’ relationship” in the President's Report of 1983 was soon eclipsed by the constraints that the Soviet occupying force had imposed on the assistance of the French Doctors.⁶² This polished image of the Western volunteer caregiver also came into crisis on the eve of the twenty-first century.⁶³

“Who is the ‘MSF volunteer’?”

The growth and professionalization of the organization (which has placed new strains on human resource issues), the introduction of “remote control” programmes with teams formed solely of national staff in areas where expatriates are commonly targeted, such as Chechnya, and the increasing number of locally recruited people wishing to become expatriates after working with MSF for several years have led to fundamental changes in “traditional” volunteer profiles since the late 1990s. These changes did not, however, come about without resistance, as MSF Switzerland president, Olivier Dechevrens, pointed out in 1999:

Is a “good humanitarian” necessarily someone who goes abroad as an expatriate to help “others”? Is it inconceivable that nationals of the countries where we traditionally carry out operations should work with MSF for the same righteous reasons as Europeans? Is their motivation solely financial, as many say? Are the motivations of our expatriates themselves always so righteous?⁶⁴

In addition to the issue of the origin of volunteers, another tension arose from the search for a new balance between skills and commitment. This question, which has revived the foundational debate between the advocates of professionalization and the critics of bureaucratization, was a prominent and recurring theme in the President's Reports of this period, highlighting the need for awareness and mediation efforts. In 2000, the president of MSF Switzerland observed: “We need more people, preferably trained, competent, enthusiastic and totally committed. That is a lot to ask and, unfortunately, the ideal expatriate is not so easy to find.”⁶⁵ The matter was brought up again the following year: “Who is the ‘MSF volunteer’? … We must promote professionalism in our work, not in the sense of ‘humanitarian careerism’, but by promoting professional skills to be employed in the pursuit of our mission.”⁶⁶

This questioning of volunteer identity once again raised the issue of the division between individual and institutional responsibility, because higher expectations toward volunteers also apply to their recruiters. This is something that the president of the Swiss section had already commented on in 1999: “Taking into account and assessing savoir-être [interpersonal skills] and not only savoir-faire [know-how] is undoubtedly one of the biggest challenges for our colleagues in human resources.”⁶⁷ This challenge was starkly highlighted in 2002, with revelations of widespread sexual abuse in camps in West Africa by aid agency personnel. Beyond the media scandal, it served as a reminder that

working in unstable or dangerous situations, in war-torn societies or in camps for displaced persons, where one may be the only provider of the assistance needed by vulnerable people to survive, places one in a position of great power to which is attached a heavy individual responsibility. Each expatriate, each national staff member must be aware of this …. All the information provided at the initial briefing before departure and all the codes of conduct, however important they may be, are only safeguards, not guarantees.⁶⁸

The focus on these questions sharpened in the following years, as the effects of the discourse of the “war on terror” aroused concern among humanitarians about how they might be perceived. As national staff came to contribute to the image of MSF, as well as playing their part in operations, the all too evident distinction between local “employees” and “volunteers” became even more problematic. This concern was voiced by Jean-Hervé Bradol, the new president of MSF France, in 2003:

We must redefine field teams. Expatriation and profession should no longer be factors accorded priority over the real nature of the work carried out on the ground. There are missions where the driver is effectively an ambassador, someone who mediates with the local power-holders and with the population; in such cases, the driver must be a full-fledged member of the volunteer team …. In practice, we must open up to national staff. This would involve a changein the association's membership.⁶⁹

The time of “terror”

While the perception of risks derives from an understanding of world and conflict dynamics, exposure to risks comes from both an institutional choice and an individual decision. However, shared lines within the MSF movement were being drawn at the dawn of the new millennium: martyrdom was definitely not an option, and since the organization had decided to remain committed to providing medical care in conflict situations, both the individual and the institutional ability to understand contexts, conflict dynamics and networking capacities would be put forward as ways to handle various types of risks, including reputational ones.

Continuity…

It should by now be clear through this overview of nearly three decades of reports by MSF's representatives that many of the issues supposedly characterizing the “new” environment facing humanitarian aid actors in the wake of the terrorist attacks of 11 September 2001 had already raised dilemmas and prompted reflection within the organization. That this should come as a surprise suggests that the rhetoric of the “war on terror” and its manifestations have largely squeezed the outbursts of threats and violence of the 1990s out of the public debate.

Risk assessment, as entrusted to volunteers in the organization's Charter, is evidently not immaterial to the collective and commonly acknowledged representation of the state of the world, and of the anticipated threats and specific risks facing humanitarians. In this regard, the events of 9/11 and their aftermath gave rise to divergent attitudes on the part of the respective presidents of the French and Swiss sections. At the MSF France General Assembly following the attacks and the launch of the “war on terror” by the US government, Jean-Hervé Bradol, the new president of MSF France, called for caution:

I remember how, a decade ago, the customary opening for any address or report was “after the fall of the Berlin Wall”. I hope that this is not going to happen with “after 11 September” …. Although 11 September was clearly a major event, it would be wrong to look at the balance of power and all developments in international relations through this prism alone. … [I]t must never be forgotten that, in any broad geopolitical analysis, there is always a tendency to assume that the world will be worse, harder and crueller in the future. [However,] there has been good news this year, with the gradual abatement of conflicts … in the Balkans, Sierra Leone, Timor and Sri Lanka.⁷⁰

In addition to being a guarantee of independence, this rejection of a totalizing interpretation was re-emphasized by Bradol, the following year, as a matter of volunteer safety:

The first line of protection [for our teams] is our own position, our understanding of the context, our ability to forge links. This is what protects us, the clarity, the neutrality and the impartiality with which we perform our mission as a humanitarian medical team.⁷¹

Exposure to risk is also a matter of institutional choice. In the same year, the president of MSF France endorsed the conscious effort by the organization to “refocus on the victims of conflicts”, after extreme dangers had led to the discontinuation of several missions in conflict areas in the previous decade and had reduced the share of this type of activity in MSF's work. It is therefore up to the organization to assume the consequences – “it is important to be aware that this has an impact on the exposure of staff members to danger” – and to define the limits of its action, although this does not prevent individuals in the field from making choices:

We must redefine the limits of this commitment. There is no question of “encouraging suicidal action” in our organization. We do not think that it is a positive thing to knowingly sacrifice your life, to go to your death to provide assistance. Each of us is free to engage in an action or not. Moreover, when situations are too dangerous, it is not only necessary to decide whether conditions are too hazardous for MSF teams to provide assistance, but also to assess whether the level of violence on the ground has reached the point where our action could actually jeopardize the safety of those we seek to help.⁷²

Technological advances in the means of communication had already been at the heart of the debate on the responsibility of programme managers and the responsibility of MSF as an organization in the mid-1990s. Jean-Hervé Bradol prolonged that debate to justify the necessary part played by the volunteers’ judgement regarding risk-taking. Defending the controversial decision that had resulted in a team being left in Baghdad when the US military operation started,⁷³ he reversed the perspective on the issue, emphasizing MSF's faith in individual initiative in the field:

How can the level of danger be assessed? There is a growing tendency to take decisions and judge the level of danger from thousands of kilometres away, by telephone, by email …. There can be no black and white approach to these discussions, with yes or no answers. The role of individuals, their determination, their enthusiasm, their network of personal relations on the ground, their aspirations, their mood that morning before getting into the car, all these are crucial factors. From this point of view, the Board considers that the best approach is to have faith in people rather than in systems and procedures when it comes to taking decisions.⁷⁴

… or a break with the past?

In the same year, Bradol's counterpart at MSF Switzerland, Olivier Dechevrens, analyzed the post-9/11 international context as a fundamental break with the past that set new challenges for the organization. During the preceding year, the Swiss section had suffered a double tragedy: the kidnapping of its head of mission in the Dagestan region, on the border with Chechnya, and the deaths of seven members of its Angolan medical staff, who were killed by a mine. Associating these events with those in Iraq, he made the following observation:

[T]he political environment has undergone profound changes since 11 September 2001. Humanitarians are faced with a dilemma, a choice that is practically impossible to make. How can we continue our work without putting the members of our teams in danger while at the same time maintaining our presence in support of the most vulnerable populations but without compromising ourselves with anyone? How can we work with a vision that is more refined than the binary perspective of the Coalition of the Good against the Axis of Evil?⁷⁵

Two years later, the new president of MSF Switzerland, Isabelle Ségui-Bitz, outlined a response to this dilemma. It was influenced by the shock of the killing of five members of MSF Holland in Afghanistan the previous summer, which had prompted all sections to withdraw from the country. While she agreed with her predecessor's view that 9/11 marked a break with the past, her analysis of security conditions and the limitations of MSF's action was more in line with that of the president of MSF France:

We are not destined to become martyrs for humanitarianism! Let's be clear on this. Our work in high-risk areas can only be carried out if minimum requirements are met and the risks we take are acceptable. There is a great deal of work that must be carried out in advance: establishing contacts with all the parties, explaining the purpose of our work again and again and promoting local contacts, while ensuring, at the same time, that we maintain our independence of action. If these requirements are not met, we must give up and leave. The world has changed since 11 September, and our work has been called into question by some who regard us as undercover agents serving in the “war on terror”.⁷⁶

The issue at the core of this analysis of the international context from the perspective of a radical break is the change in the perceptions that “some” have of humanitarians, which, as in the early decades of MSF's history, have more to do with political and military actors than with the populations of the societies where volunteers work. The primary responsibility of the organization is to work actively to restore these perceptions and ensure that “all parties”, starting with those targeted in the “war on terror”, do not misunderstand MSF's identity and its objectives. The only way to put this into practice is through the day-to-day work of its field volunteers at the local level.

The La Mancha Agreement⁷⁷and beyond

The combination of these “external challenges” and profound changes in the organization and the way it is run prompted the International Board of MSF and the general directors of the then nineteen sections to launch the La Mancha process in 2004. Based on a broad consultation involving MSF members and knowledgeable non-members, the process was designed to establish a new intersectional agreement allowing the organization to better define, in the words of MSF's international president, its “basic raison d’être” and its roles and limitations in this new period of its history.⁷⁸ The La Mancha Agreement was adopted in June 2006. The text that serves as a preamble includes an overview of the changing international environment proposed by the members of MSF's International Board. This closely resembles the one given by Isabelle Ségui-Bitz, although the suggested time frame is longer than that of the “war on terror”, as if to distance itself from that discourse:

In recent years we have seen the multiplication of military interventions that include the deployment of a “humanitarian” component among their strategic goals (Kosovo 1999, Afghanistan 2001, Iraq 2003) and the emergence of political and military forces that reject our very presence. This reality has led us to define our understanding of risk, and the reaffirmation of our independence from political influence as essential to ensuring the impartial nature of our assistance.⁷⁹

This independence is essentially reflected in two of the agreement's articles. While Article 1.1 establishes that “[p]roviding medical assistance to the most vulnerable people in crisis due to conflict [remains] at the core of MSF's work”, Article 1.10 stipulates that the organization “intervenes by choice – not obligation or conscription – and may decide not to be present in all crises, especially when targeted threats against aid workers exist”.⁸⁰ Article 1.11 also establishes the collective responsibility to “strive to prevent the work we do and our assets, both symbolic (i.e. our trademark and image) and material, from being diverted or co-opted for the benefit of parties to conflicts or political agendas”.⁸¹ Unlike the MSF Charter, the La Mancha Agreement is concerned above all with the collective responsibility of the associations that make up the MSF movement. The issue of the individual responsibility of volunteers is addressed not with regard to their safety, but in connection with their behaviour, specifically in Article 2.5: “MSF staff members are personally responsible and accountable for their own conduct, in particular regarding abuse of power. MSF is responsible for establishing clear frameworks and guidelines for holding staff accountable for their conduct.”⁸² The focus here, again, is on how the organization not only can improve its practices – and there are several provisions on the institutional commitment to improve care practices – but also controls its image and therefore the perceptions that it creates outwardly, which could be adversely influenced by the conduct of its volunteers.

Although the La Mancha Agreement establishes an intersectional consensus defining how the organization deals with risk in the new international environment, it does not address the question of the balance between individual and collective responsibility in matters of security. It is during the process of consultation undertaken to develop the Agreement that two positions emerged on this subject, standing out as two poles delineating the spectrum of views within the organization.

The first, voiced by the director of operations for the Dutch section at the time, Kenny Gluck, called for MSF to ensure “a greater sense of respect for the right of individuals, committed to the provision of assistance to people in crisis, to accept the risks involved in providing assistance”. Although Gluck did not explicitly refer to the organization's Charter, it was no doubt the founding document he had in mind when he questioned the basis for “an institutional limit for risk – even where it is taken freely, consciously and legitimately”.⁸³ He concluded:

The balance between the individual right to take risks in order to provide assistance and the institution's right to limit this risk touches on the identity of MSF as an organization of volunteers …. Respecting the essence of a volunteer organization requires MSF to respect the individual yardsticks against which we balance humanitarian assistance against risk and reject the tendency for this to be subsumed into the systems and hierarchies of MSF the institution.⁸⁴

Reviewing this line of reasoning in order to more clearly refute it, Pierre Salignon, general director of the French section in 2005, sought to reaffirm that the onus of responsibility for establishing what level of risk is acceptable lies with the association:

[V]olunteers and those in charge of operations could, in the name of humanitarian principles, undertake initiatives that put in danger their own lives or those of their colleagues in order to open up so-called humanitarian space in the universe of extreme violence, even if it means going against (or without) the advice of their association, regarded as bureaucratic or too overcautious. … [I]f security management in the field covers individual aspects and there is a place for each person to express their views, decisions about taking risks are, on the contrary, a collective matter, going beyond personal choice alone, and are the reason why the association may sometimes decide on the basis of security reasons to terminate a project or a mission against the opinion of the teams in the field. It is not a question of the Boards arbitrating over operational decisions; rather, it is one of setting the benchmarks enabling those who put the operations together to measure the risks for the populations and for those seeking to bring them help.⁸⁵

Since the La Mancha Agreement, views within MSF have continued to fluctuate between these two poles, reflecting differences that can probably be more properly attributed to varying sensibilities than to opposed visions and that are not specific to one section or another, but spread across the movement as a whole. The position expressed by Jean-Hervé Bradol during discussions at a Board meeting in 2008 may thus be seen as a middle ground between these two poles. While defending a definition of volunteering that gives precedence to individual initiative and choice, he also upheld the sections’ function of setting “benchmarks” for the action of individuals: “Volunteering does not release us from responsibility, but reverses the perspective. We are there because there are volunteers who represent us and take decisions for themselves. Our responsibility is to ensure that certain requirements are met”.⁸⁶ These requirements were clarified at the MSF France General Assembly held the same year, a few months after a young expatriate had been killed in the Central African Republic. It is the responsibility of the organization to:

ensure that the teams are providing meaningful assistance, that their action is effective and not merely a symbolic presence to defend a cause; … [and to] ensure that care is taken to prevent our assets, both material and symbolic (our emblems, our identity), from being diverted, notably to military purposes. A limitation we also impose is that when a political group … announces that it intends to target aid workers and kill them, in areas where these groups have enough influence to carry out their threat, we will not support that teams remain present on the ground.⁸⁷

With these caveats, “the decision to expose oneself to danger remains an individual choice” and volunteers are free to change their mind and “stop at any time”.⁸⁸ Jean-Hervé Bradol reaffirmed his conception of volunteering as the driving force behind MSF's action with the following words: “If we are able to maintain a presence in particularly dangerous areas, it is thanks to the sum of individual decisions which the association supports with the means and resources at its disposal.”⁸⁹

Conclusion

Various factors have influenced changes in the interpretation of the Charter with regard to the balance between institutional responsibility and individual responsibility for risk-taking. An important factor is obviously the growth of the MSF organization itself, from a small French association with a pioneering spirit in the early years to the multinational, professionalized movement it is today. Complex internal balances, the development of the decision-making structure and the incorporation of technological and human resources to manage and control operations have clearly altered the terms of HQ responsibility. The ramifications of these changes need to be nuanced, however. While new means of communication have changed the way in which risks are assessed through the necessary process described by Rony Brauman as “combining and contrasting points of view” from HQ and from field teams,⁹⁰ the illusion of virtual proximity in decision-making has been frequently criticized. Over the four decades of MSF's history, volunteers’ profiles, their skills, their geographic origin, their personal experience and their status have also been constantly changing. This new sociological and cultural complexity sets new limitations on forms of authority and communication and on criteria for determining acceptable risk for field teams and the individuals that make them up. In this regard, current concerns about the influence of legal obligations such as the duty of care on humanitarian organizations, and the restrictions that they place on risks run by volunteers, must also be put into perspective. These concerns emerged in the mid-1990s, accompanied by the adoption of codes of best practice by aid agencies.⁹¹ It was also at this time that the Sphere project was launched to develop quality standards for international aid.⁹² MSF withdrew from the process on the grounds that the adoption of minimum technical standards was likely to lower quality requirements for aid agencies overall while leaving unaddressed the question of their responsibility for the actual use of aid and possible attempts to turn it against its intended beneficiaries. Should the legal responsibility of “MSF the employer”, then, be the prime mover in risk reduction and the provision of information for volunteers departing for dangerous areas, along with any other assistance the organization would be expected to give them?

Since the La Mancha Agreement, and particularly in recent years, there has been no lack of dangerous contexts for MSF, imposing new limitations on its action. In 2013, all the operational sections withdrew from Somalia following the kidnapping of two Spanish section volunteers, who were held for almost two years. The following year, five volunteers from the Belgian section were abducted by the armed group Daesh in Syria, leading to the discontinuation of all MSF programmes in areas under the control of this group in Syria and Iraq. Events such as these fuel the perception that the “time of terror” is not yet over: political and criminal “terror” inspired by groups such as Daesh and Boko Haram; biological “terror” caused by the Ebola epidemic in West Africa and the exposure of volunteers and their national colleagues to real contamination risks. Yet, the link commonly made between these two realities to highlight the increased level of danger for humanitarian actors is echoed in the commentary of historian Bertrand Taithe, who observes that “[t]he idea that Ebola has become almost primarily a global security threat says a lot more about our militarised world view than about the disease”.⁹³ While it is true that MSF has withdrawn its volunteers from Somalia and Syria, it has also recently redeployed teams in Afghanistan after a six-year absence.⁹⁴ This is a reminder not to make assumptions about the future and to acknowledge the fluidity of contexts characterized by a high level of violence. The risks involved in managing the Ebola crisis mean that MSF the organization now has to contend with new responsibilities towards its volunteers, which will no doubt be an issue again in the future.⁹⁵ However, Time magazine's choice of Ebola fighters for Person of the Year 2014, including several members of MSF's local and international staff,⁹⁶ is proof that social expectations and respect for the individual commitment still associated with humanitarian volunteers belie the trend suggested by the debate on the duty of care, which would make the relationship between MSF and its volunteers an employer–employee relationship like any other.

Throughout MSF's history, the occurrence of particularly serious incidents provoked, for a time, a prevailing sense of rupture throughout the movement, when the letter of the Charter and the individual responsibility of volunteers took a backseat to institutional responsibility. However, as the choice, consistently reaffirmed by all the operational sections, to put assistance for conflict victims at the heart of their work implies, it is the faith that the organization places in its volunteers – or at least, in highly dangerous situations, the most experienced of them – that enables it to pursue its mission. Essentially, while the institution's responsibility for assessing risk undoubtedly has greater legal content than the individual responsibility of volunteers does on the basis of the MSF Charter, there remains a shared responsibility to find the right balance, always momentary and context-specific, between the two.