Medical professionals providing humanitarian aid are divided over whether to hold to medical confidentiality and political neutrality or to speak out about the atrocities they witness.

[Note: this is not written as a typical Lesswrong post, and was part of a challenge to write something in the style of a journalist article.] 

Along with all the many challenges of aid work, from lack of funding and supplies, to directly putting themselves in the line of violence, medical providers responding to humanitarian crises are often faced with an agonizing dilemma. On the one hand, they often witness terrible atrocities, where publicly speaking up is necessary to address the root causes and hold governments accountable for their actions. On the other hand, remaining silent and neutral can be the only way to stay in regions with ongoing humanitarian crises. 

Can an organization ostensibly focused on medical work, staffed by doctors and nurses, carry out political advocacy anywhere near as effectively as a group specialized in it? Perhaps more importantly, can they do so without compromising on treating those most in need? 

Doctors Without Borders, a major humanitarian medical relief organization, has faced this choice over and over, often resulting in controversy. They were at one point accused of being manipulated by the CIA. Aid workers were murdered in Afghanistan. Over the last five decades, they have debated – and even schismed over – this question, but not yet answered it. 

A brief history of Doctors Without Borders 

In 1968, a small team of doctors volunteered with the Red Cross – despite its name, not a medical organization – to provide medical care during a war and famine in Nigeria. The experience was horrifying; emergency medicine couldn’t save people starving due to military blockades of food shipments, and the hospitals where they performed emergency trauma surgery were frequently targeted by the Nigerian military forces. They believed that political action was necessary in order to address the humanitarian crisis, and came to see the Red Cross’s commitment to neutrality and required oath of discretion as complicit. They openly criticized the Nigerian government, as well as the Red Cross for its handling of the situation. Three years later, these doctors joined the founding team of ‘Médecins Sans Frontières (MSF), or Doctors Without Borders. 

Since its inception, MSF has continued to send relief missions all over the world, providing medical aid in the aftermath of natural disasters such as earthquakes and floods, as well as wars and refugee crises. The organization now employs more than 30,000 people globally and has treated over a hundred million patients. 

MSF plays out a difficult balancing act, judging when they can save the most lives by remaining silent and cooperating with the local authorities, or even with criminal groups. In their 2011 publication, Humanitarian Negotiations Revealed, they reveal having paid “registration” fees to an Al Qaeda-affiliated group in order to continue relief work in Somalia. To avoid being banned from Yemen after listing the country as one of 2009’s top ten humanitarian crises, they issued an official apology to the government. 

And five years after pulling out of Afghanistan after five of their staff were murdered by the Taliban, they were able to return – by opening two projects, one in a government-controlled area and one in a Taliban stronghold. Having demonstrated their commitment to helping everyone in need, regardless of what side they were fighting for, MSF was able to earn enough local trust to continue their work.  

The case for political advocacy 

In many instances where humanitarian aid is called for, the root of the problem is political, and much, much larger than anything a small team of doctors with some supplies can fix. This is what the Red Cross volunteers experienced in Nigeria, and the early staff of MSF repeatedly faced the same situation. 

In the first half of the 20th century, international aid generally involved working with the cooperation of the local authorities – a strategy with obvious problems, when human rights violations are being perpetrated by a government. Bernard Kouchner, one of the volunteers in Nigeria and a founding member of MSF, wrote about the right to interfere, arguing that it was the duty of aid workers to break rules and cross borders in order to help those most in need. 

Kouchner was criticized for his “publicity-seeking” approach to aid, but he believed that raising awareness of the atrocities that they were responding to was, in fact, a critical responsibility of aid organizations; media coverage would rally support toward the immediate crisis, and also create political incentives towards addressing the underlying causes. In 2004, he argued that “the media creates pressure on public opinion. Without this pressure, there is no pressure on politicians, who are sensitive only to pressure from people within their own countries.” After ongoing disagreements around his approach, Kouchner left MSF in 1979 to found a parallel organization, Médecins du Monde, or Doctors of the World.

In 1980, MSF faced criticisms over their controversial “March for Survival” at the Cambodian/Thai border, where hundreds of demonstrators and journalists arrived with a food convoy and made public demands for independent, internationally-monitored distribution of relief. (Somewhat complicating this narrative, it later turned out that there was not, actually, a famine.) One of the MSF representatives, Claude Malhuret, responded to demands that MSF should “do humanitarianism, not politics”, with: “This is politics in the true sense of the word. People are dying of hunger in Cambodia, and we can’t intervene. If you had known about Auschwitz, would you have buried your head in the sand?” The history of the 20th century certainly holds some ugly examples of what happens when individuals, organizations, or nations fail to intervene against atrocities committed by another government. 

The case for neutrality 

Unfortunately, engaging in political advocacy is not without costs for humanitarian organizations. Cooperative relationships with the local authorities make relief efforts much easier to manage, and publicly denouncing a government’s actions can result in an organization being banned from the region. Fundamentally, humanitarian organizations need the trust of the people they are coming to help, and this becomes more difficult if the organization is seen as pushing a political agenda. In the wake of the Cambodian demonstration, for example, there were accusations that MSF had been manipulated by the CIA into spreading propaganda on behalf of the US government. The organization’s actions may have been reasonable, but given that MSF saw part of their mission as promoting democracy in the name of human rights and freedoms, and received funding from a foundation dedicated to spreading American “soft power”, the claim seems not entirely false.  

Fabrice Weissman, research director of the MSF Foundation, believes that the politics around international aid became even more fraught after the end of the Cold War, and “Aid came to be considered not as humanitarian relief, but to serve a political agenda in nation-building projects.” And when aid workers are seen as political actors, they can themselves become targets. This is exactly what happened in Afghanistan in 2004, when five MSF aid workers were murdered by the Taliban. As a result, MSF had to withdraw its relief efforts, snatching away support from the people they were there to help. 

According to Scott Lea, a Doctors Without Borders field coordinator: “In many instances, [neutrality is] a key part of us being able to access beneficiaries to be able to explain to actors, whether they’re government or non-state actors, who we are, and that we’re not part of the conflict. Whereas, if we came in with an agenda, if we came in with a bias or support from a particular government, very often that can make access to beneficiaries even more challenging. [At an even] more micro level, if beneficiaries don't see us as neutral, then very often they would be less willing to accept or to access services that we provide.”


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