Can Médecins Sans Frontières (MSF) be first responder, advisor and activist, all at the same time? While the organisation has never seemed to be on the front line with regards the effects of the “migration crisis”, the question is still being asked internally, particularly in the French section. All credit to Michaël Neuman – and his role at the Centre de Réflexion sur l’Action et les Savoirs Humanitaires (CRASH) – for leading this discussion.
After abandoning Europe – and France in particular – for several years, the French section of Médecins Sans Frontières – where I work and the sole subject of this analysis – has returned. In summer 2015, it launched a series of aid projects for migrant populations in Greece and northern France, before gradually moving into other regions of the countryEven though they are outside Europe, the projects launched in Libya and Niger are also directly related.. These decisions were not taken without debate, with powerful voices within MSF promptly speaking up to stress the risks that these programmes posed for the organisation. This concern was partly based on recollections of MSF’s operational activity in France and its radical practices (some would call them “exuberances”) of the 1990s. The fact that these populations had no “medical needs” was also highlighted.
These operations were therefore deployed in a climate at times tinged with scepticism. This forced project managers to consider the public and operational position that an intervention in a wealthy country (which is also the organisation’s base) should adopt with populations whose needs required an in-depth revision of its operating methods, and which would inevitably be accompanied by the adoption of sometimes-radical political positions. In this article I shall try to explain this occasionally difficult relationship between operational constraints and political positioning by attempting to describe and analyse how the issue of migration proved to be a shock for the first responder organisation.
Shall we wipe the slate clean?
At this juncture I feel it is important to explain why I shall make no reference in this discussion to what built MSF and its legitimacy, starting with its work with refugee populations in camps, initially in South-East Asia, then in Central America and finally Africa. MSF played its part in challenging the totalitarian systems in Eastern Bloc countries by highlighting that the overwhelming majority of refugees were fleeing those very countries. It was the controversy surrounding the assistance given to the “boat people” in the China Sea that triggered the split between the founder members of Médecins Sans Frontières. Similarly, public challenges raised by Western countries on the fate of refugees is nothing new; in 1990, Rony Brauman, former president of MSF, published an article in which he demonstrated that images of refugees had lost their power in our collective and political conscience in the immediate aftermath of the fall of the Berlin WallRony Brauman, « Réfugiés, Go Home ! », Politique Internationale, n° 47, printemps 1990.. Even though the social resonance of the migration issue is not the same in 2019 as it was in 1990, the perpetual nature of the challenges is staggering. Lastly, MSF’s experience with migrant populations in Europe did not begin in 2015. In early 1983, when Nigeria expelled around two million African migrants who were, in the words of Rony Brauman, “driven back by horsewhips and clubs”, Brauman described their situation in MSF’s annual report as follows: “Both MSF teams, that had entered the country through Togo, could only confirm the situation. Exhausted and terrified, those who were being expelled however showed no particular medical problems . The situation was clearly way beyond the capabilities of an organisation like ours and, from a technical point of view, the role played by this mission remained an extremely modest one.” He concluded by underscoring “the nature of our intervention, as derisory as it may be, is yet full of meaning: that of a certain kinship with these men plunged into misery and humiliation.” Any resemblance with current times is obviously not coincidental.
The decision to limit this analysis to recent times and the migrations that are the subject of much debate in Europe is therefore partially arbitrary. It can be justified very precisely by the European context in which the migrations are happening, and by the specific relationship that connects MSF to the originating countries.
MSF in France: a long history
Launched in 1987, the Mission Solidarité France owes its origins to the discovery of a “new poverty” following the publication of a report by Joseph Wresinski, founder of the movement ATD Quart Monde. It was the shock of seeing people in the streets on their doorstep that encouraged a group of MSF doctors to act, demonstrating that the principle of impartiality to which it frequently clings is not particularly useful in understanding the mechanisms used to allocate the association’s resources.
For MSF, the introduction of its activities in France must also be understood in the context of its competition with Médecins du Monde (MDM), which launched its “Mission France” in 1986. In addition, but to a lesser extent, the rivalry between French organisations seeing a need as well as an opportunity to raise funds was also a factor.
At the time, MSF was developing its free healthcare and dental activities and its measures against lead poisoning. Its aim was to alert France’s public authorities to the existence of gaps in access to healthcare for the most at-risk sections of the population, regardless of whether or not they were French. The mission was based on a lightweight operational structure consisting of a small number of healthcare centres, the goal being to gather evidence and have the legitimacy to generate a political message without giving the impression of replacing the State.
A few years later, in 1994, Philippe Biberson, the organisation’s President at the time, explained MSF’s interest in providing healthcare beds “as French doctors and as a medical organisation operating on French soil”. The intervention in France was therefore somewhat exceptional due to its proximity to its social base and MSF’s perception of the role of the State in Europe, and particularly in France.
These efforts were the result of partnerships with groups and other organisations, including MDM. Thus a group of thirty-five organisations mobilised against the expulsion of undocumented foreign nationals suffering from serious diseases. MSF also worked with government ministries to develop free medical care (1991, Édith Cresson Government) and the drafting of the concept of a universal right to health insurance (1995, Alain Juppé Government).
In October 1996, a project for “social services and legal support for foreign nationals resident in France” was put to the vote at MSF’s Board of Directors due to its “non-medical and unusual” and, in a word, “exceptional” nature. It was designed to demonstrate “our split from the charity sector”. Some members of the organisation took part in demonstrations aiming to prevent the expulsions. The work undertaken for the universal medical cover policy (CMU) from 1997 would confirm that MSF had indeed abandoned its exclusive role as first responder. Advisor to cabinet ministers as well as campaigners for access to healthcare for foreign nationals, MSF had changed its image. The adoption of the CMU in 1999 would mark the highpoint of a programme promoted internally by a group of determined figures, themselves supported by the organisation and driven by a specific political vision: a belief in a robust public service for the benefit of all. At least two additional features characterised the mission: a desire to tackle public policies, and ongoing partnerships with other organisations, members of the political establishment, unions and institutions.
After the rise, the fall
In May 2005, when alluding to access to healthcare and exclusion programmes, including what is now known as “Mission France”, MSF’s President Jean-Hervé Bradol stated: “We are unable to deliver a quality action in the timeframe required for such complex issues . ‘Social progress’ primarily comes under political and social action and not under humanitarian actionMédecins Sans Frontières, President’s report for 2004, General Assembly, 2005..”
This did not mean that Mission France was closed. A project to provide psychological care to non-Francophone asylum seekers – failed or otherwise – was launched in Paris in 2007, despite opposition from the organisation’s President. With Sarkozyism on the rise and then victorious, there was little doubt in some of his supporters’ minds that the project would evolve into a tool to oppose the immigration policy pursued by the new French Government and, furthermore, European governments. However, the initiative was ill-conceived, and to avoid exposure to accusations of radicalism, the teams partially renounced the public actions that had been a feature of previous projects.
The organisation’s position was all the more precarious since the government was making an increasingly clear distinction between “good” (i.e. humanitarian) organisations, subscribing to the idea of assistance, and “bad” (i.e. activist and political) organisations. While the European States, led by France, had decided not to let the migrant populations die, they de-legitimised any political actions developed to support them, thus leaving only room for health-related action.
The project no longer had any collective support and tensions between the project teams and managers at head office were running high, added to this, there was disorder in the mission’s administrative management. Barely mobilised by the project’s low level of activity and convinced that no-one would die even if it were brought to a halt, operational management decided to close the mission, which it did in 2012. However, other MSF sections, including the Greek, Belgian, Italian and Spanish sections in particular, would continue to carry out relief operations for migrant populations on their own soil or in North and West Africa.
In the summer of 2015, and after seeing images of the exodus of refugees from the Balkans, MSF felt compelled to reconsider its operations and its role in Europe. A little earlier, the Dutch section and the NGO, Migrant Offshore Aid Station (MOAS) had launched a relief operation in the Mediterranean and were subsequently joined by the Belgian section, which launched its own rescue operation. For the French section, which took on the role of a powerful intermediary for the operation, this was a way of regaining a foothold in the issue. With population movements on this scale, it realised that it had to fully commit itself.
Memories of the difficult closure of Mission France were still fresh in people’s minds, and with them came two questions. Firstly, what should the response be, given that most of these migrants were not ill and that MSF considered its “added value” to be low? Secondly, was there not then a risk of delving into “politics”, a word which some consider incompatible with the principle of neutrality claimed by MSF?
To both questions (the provision of medical services and, ultimately, of speaking out) a succinct reply was given: let’s engage, and we’ll see what happens. Actually, many people thought that it was impossible for us not to get involved, and furthermore, that this was happening “at home”. This was an implicit admission, like their predecessors in the 1980s, that these problems affected us differently. After a series of lively discussions where many operational managers still thought that this was no place for MSF and that it was too “risky”, evaluation missions were launched in Greece, the Balkans and northern France.
In doing so, the organisation was simply acknowledging that it was not operating outside its remit: it made no sense, internally or externally, to do nothing while lines of refugees and orange life jackets were filling our screens. In this respect, the shock that this migration sent through MSF was initially the same as that felt by French society. But questions remained.
Operationally speaking, MSF had to reinvent itself. The type of aid to be given to migrants and refugees is a recurring problem for the organisation: in its collective subconscious, MSF places the greatest value on actions that aim to reduce mortality. In Greece, Italy and France, however, those people embarking on the difficult journey to northern Europe are, in many respects, “survivors”. Most of them are men in good physical shape and good health. Medical needs often concern minor injuries, skin diseases and, occasionally, chronic diseases, whilst for women they concern childbirth and pregnancy monitoring. Many express or demonstrate a need for psychological and psychiatric treatment, associated just as much with the trauma of their past experiences as their journey and the lack of prospects in their current situationPia Juul Bjertrup et al., “A life in waiting: Refugees’ mental health and narratives of social suffering after European Union border closures in March 2016”, Social Science & Medicine, … Continue reading. Some, of course, are more vulnerable in terms of health, but in their desperate race towards sanctuary it is mainly material needs, requests for information and social and legal aid that prove to be most urgent. With regard the construction of camps, such as La Linière, contrary to popular belief this is not part of MSF’s day-to-day remitSee Franck Esnée and Mickaël Neuman, “Sheltering, hosting or receiving refugees: the unresolved ambiguities of the La Linière refugee camp”, Humanitarian Alternatives, n°.5, July 2017, … Continue reading.
The revolution required is quite simple to define: to focus relief policy on personal autonomyĊetta Mainwaring, “Migrant agency: Negotiating borders and migration controls”, Migration Studies, Vol.4, n°3, 1 November 2016, p.289-308, https://doi.org/10.1093/migration/mnw013, and provide people with the services that are useful to them on their journey. And then do something else, such as provide protection in Libya or guidance with procedures in France, a per-user cost which is quite high. Although there is broad consensus on “what we see”, it is always difficult to go any further: how can we enter the migration debate without being prescriptive? What expertise can we claim? Comfortable with the subject of asylum, the organisation is much less so when dealing with migration; and with regard to expertise, there is a huge risk of reaching an uneasy compromise. This is how the deliberately vague concept of “safe passage”, which first and foremost highlights the dangers that current policies pose for people, was preferred over others.
But this vagueness reveals MSF’s discomfort. On the one hand, this discomfort will partially dissipate as the organisation gradually faces up to reality and, on the other, as it is exposed to technical reports. The projects implemented in Greece, France and Libya are gradually allowing us to assess the level of violence generated by the migration policies put into practice around the Mediterranean, and the modest means the organisation has at its disposal to contest those policies and address the violence. Furthermore, work in the field of social sciences – I am thinking particularly of Karen Akoka’s work on constructing the figure of the refugeeSee Karen Akoka, « Crise des réfugiés, ou des politiques d’asile ?», La Vie des idées, 31 mai 2016., Charles Heller and Lorenzo Pezzani’s work on sea rescueSee Lorenzo Pezzani and Charles Heller, “Liquid Traces”, 2014; “Death by Rescue”, 2016 and “Mare Clausum”, 2018. and the Babels research programmehttps://anrbabels.hypotheses.org – can be used to enrich and challenge the organisation’s own analyses.
It is through this greater intellectual conviction and a more consistent operational experience that the organisation can speak out and throw the hitherto-observed caution to the wind. It is asserting itself as an advisor and adopting positions that place it firmly in opposition to State practices.
Between subversion and balance: a constant quest
For all that, migration itself has been the subject of numerous discussions and initiatives. The MSF movement quickly became a household name thanks to its Twitter account @MSF_Sea, dedicated to monitoring relief operations at sea. But the repeated and strikingly telegenic and disturbing images of rescue operations and (often white) European “rescuers” soon proved unsatisfactory and insufficient. MSF went looking for personal stories (published on the dedicated Facebook page “Voices from the Road”https://www.facebook.com/MSF.VoicesFromTheRoad/, which was launched in 2015 with the aim of gathering the life stories and personal experiences of migrants) and drew on its partnerships with photographers (ref. Bruno Fert and the “Itinéraires intérieurs” projecthttps://www.msf.fr/evenements/exposition-photo-itineraires-interieurs-a-paris).
Other initiatives, designed to be highly innovative, were also developed, such as MSF’s six-part web-series Johnny Hunterhttps://jenesuispasjohnny.msf.fr/page/episode?pageId=2 which caused major controversy within the organisation, with some deeming it vulgar and inappropriate. These means of expression used by MSF to speak out have continually been viewed as an institution publicly expressing criticismhttps://www.msf.fr/eclairages/assistance-aux-personnes-en-migration and even personal criticism (as was the case with the open letter written in my name to French MPs representing the La République en Marche party in June 2018Michaël Neuman, « Secours en mer, Libye et politique migratoire: Lettre ouverte aux député.e.s LREM », Blog de Médiapart, 30 juin 2018, … Continue reading, an article written by Jean-Hervé Bradol and another by Rony Brauman, both of whom were Directors of Studies at CRASHJean-Hervé Bradol, « De l’État passoire à l’État passeur »,Le Monde, 10 septembre 2018, https://www.msf-crash.org/fr/publications/de-letat-passoire-letat-passeur; Rony Brauman, « La … Continue reading).
We are never more publicly heard than when we carry out efficient, useful and slightly subversive relief operations. And in our case, despite some notable exceptions, we only have been heard to a limited extent. Since the spring of 2015, the sea rescue operations have provided a response to the shipwrecks while demonstrating the considerable deficit in the capacities for intervention. They continued until 2018, mainly through a partnership between the MSF Dutch section and SOS Méditerranée after this organisation ceased working with Médecins du Monde. These operations allowed increasing pressure to be brought to bear on States, as was the case with the migrant camp in Grande-SyntheSee the documentary La Ville Mondedirected by Antarès Bassis (a Les films du Balibari production), http://www.balibari.com/films/la-ville-monde-the-world-city, which no doubt belongs to that category of activity which significantly improves the quality of life of its target population and changes the power relationship with national authorities forced to accept an official camp on their country’s soil.
In recent times, tougher political practices in Europe have reopened the debate about MSF’s position. Faced with tougher national policies since 2017, and even more so since Matteo Salvini was appointed Minister of the Interior in 2018, the Italian section has widened the debate against a backdrop of judicial harassment and falling donations. There are ongoing tensions between an executive which can appear anxious to maintain its operations and not alienate its social base and donors, and an associative base (within the board of directors in particular) which at times is more drawn towards activism. For the time being, the French section has been spared such discussions, but given the way the political debate is changing, there is nothing to prevent us from thinking that this may soon be the case.
This unpublished text is taken from a paper presented by the author at the conference “Documenting ‘shock experiences’ of migration: towards a transformation of social representations” University of Poitiers, 7-9 November 2018.
Translated from the French by Derek Scoins
ISBN of the article (HTML) : 978-2-37704-466-5