What’s a Little Aid Between Friends?

[Apologies for the gap!  Been too busy.]

Whenever I open the internet the same vital message greets:  “Medical Aid Where it is Needed Most – Independent, Neutral, Impartial.”  That’s the top of MSF-UK’s web page.  Here’s the current headline:  Hurricane Sandy  MSF Teams in New York to Help Those Hardest hit by Sandy.  It has been a top story on the website for over a week.

The last few blogs have looked at the core humanitarian principles.  Not about how they come under attack by those opposed to our brand of goodness – badboy militia groups, depraved dictators and Western leaders who want aid to do their bidding – but how it these lofty values have Savile-ized by us, humanitarians who enshrine these principles in the Ark of their very being.

Impartiality is a particularly directive principle.  It instructs that humanitarian aid doesn’t go to your friends and neighbours just because they are needy; decisions can’t be based on religion, ethnicity or relationship to the country’s finance minister.  That leaves only one legitimate basis for decision-making:  need. And it implies finding those most in need rather than simply needs per se (i.e., go to DRC and everybody has needs, but where are they greatest?).  As Mark Bradbury concludesAssistance that is policy-driven, rather than provided on the basis of need, is no longer humanitarian.

In theory, impartiality works pretty easily in a health clinic – take the malnourished infant with malaria before the pregnant woman with a broken finger.  It gets harder as the distance grows.  Behind Door #1 Syria: violence and displacement and war-wounded. Behind Door #2 Chad: pockets of malnutrition, measles and very poor health services or infrastructure.  How do you compare suffering?

It’s no secret (actually, sadly, it is) that the major aid agencies have bent their principles in self interest, or because means were deemed less important than ends (see “Humanitarian Negotiations Revealed” for an MSF compendium of compromise).  Home society operations like those in NYC lie at the crossroads of humanitarian action and institutional needs.  It’s only a few years ago that MSF was running operations in Luxembourg, for chrissake.  GDP is over $106,000 per person. If there, then emergency botox in Beverly Hills makes sense.

Questions have always surrounded the medical impact of these missions, which can appear almost frivolous when juxtaposed against the massive needs in places like DRC or Sudan.  Normally, though, the organization admits a certain degree of self-interest in mounting these missions, a certain acknowledged violation of impartiality.  The rationalization comes later: these activities are, after all, comparatively insignificant.

But what happens when we no longer acknowledge the compromise?  What happens when we claim to be justified in these interventions, on the basis that we have responsibilities as a civil society actor?  No doubt whatsoever that Sandy has provoked health needs in the NY/NJ area (although far greater ones in Haiti, like the increased cholera to which MSF is responding, though in comparative obscurity judging by our own websites).   But if there had been no MSF in the US, would the organization have sent in the troops?  No way.   So what does that mean for impartiality?

As MSF sections in Greece and Spain look in their own back yards, they too find health needs: health systems making drastic cutbacks under economic austerity measures that offer succor to banks and pain to people.  I understand the push in headquarters, the outrage of our Greek staff and donors,  the push from the local community, and the pressure of expectation.  A little compromise is fine, isn’t it?  I mean, it’s just between us.  How to explain to the Greeks who are living this mess that their MSF can’t respond to their crisis?

Well, we do that sort of explanation all the time in countries where there are greater needs though, of course, less affiliation.  There, we are a global actor, magnanimous to offer assistance and hence privileged to deny it.  There, we sometimes go home, as has been done in the face of stunningly bad, though “developmental”, health needs:  closed programs in places like Angola, Liberia or Sierra Leone.

The key point here is that a humanitarian organization must maintain its legitimacy precisely through its refusal to be a civil society actor; through a clarion refusal to privilege localized constituencies over the only constituency that we possess – the whole of humanity. Impartiality operates from the starting point that all human life is inherently (and equally) precious. The idea of preferential treatment should be anathema to humanitarian action, and we must fight the urge to privilege the needs of people who are, literally, close to home.

Why send doctors to Brooklyn?  Well one reason is that there are people there in crisis.  But what level of unmet medical needs in the wealthiest nation on earth?  So it is also because decisions are driven by television, by a social and political proximity to the victims.

As Nick Stockton has put it:  “‘[T]raditional’ humanitarian assistance is concerned first and foremost with the task of saving lives in imminent danger, the notion of a moral or political ‘triage’ that somehow separates the deserving from the undeserving beneficiary, is for many humanitarians ethically repugnant.” Acting upon a supposed responsibility as a civil society actor equals political triage. In the end, there is something fundamentally contrary to humanitarian action and to impartiality if we intervene on the basis that some victims are more deserving than others because of their relationship to us.

9 thoughts on “What’s a Little Aid Between Friends?”

  1. Marc, You write so well, so compellingly, so interestingly. I have no real comment other than that your posts make me think very deeply. They also make me cry, because there you are so close to so many crises while I sit in such comfort nearly all of the time and my heart aches for people suffering all over the world. I try to spread joy and love among the people I come into contact with, because I know I will probably never be on the frontlines. I am so full of admiration and appreciations for those who are.

  2. Thanks Natasha. Funny thing about frontlines. They’re not where you think they are. In fact, I’d say they’re all around. Just have to look!

  3. Dear Marc,

    When I started in this business, one of the (paraphrased) quotes that gave me pause for thought was, “The way to be happy is to make other people happy, and the place to be happy is where you are”. Twenty years on, and it seems exceedingly simplistic when compared to all the criteria, principles and moral questions we use to allocate resources ‘appropriately’. But, how do we apply triage from a distance? And how do we make our triage comparative; the suffering in front of us, when compared to the suffering in a totally different context?

    I personally love that MSF applied some of the mental healthcare skills learned in Baghdad and Nablus and Helmand to the survivors of Hurricane Sandy. I agree that flying Iraqi or Palestinian psychologists in to NY would be an inappropriate use of resources (and also presumably quite challenging due to the Patriots’ Act or whatever the relevant US legislation is). But the degree of mental suffering caused by losing everything you own to as hurricane is very likely, from the clinical perspective, comparable to that of losing it to a coalition bombing raid.

    I don’t disagree with you; I see the application of humanitarian principles in giving aid in the richest places on earth as challenging. But we’re delicate creatures, with an extremely fine line between resilience and collapse. Tough circumstances harden us as humans; we tend to have greater admiration for the person that walks three days across the Sudanese Nile floodplains in search of care than for the overweight New Yorker who stands in the matchwood ruins and cries, “Why me?”. But, since we’re there on the spot, and we can offer a helping hand, it’s not a moral dilemma – it’s a genuine impartial humanitarian response.

    Apologies for the rather long comment – not enough to keep me busy right now!

    1. Hey Paul,
      Thanks for the brilliant comment. You’re right that it really isn’t proper to compare suffering at a global level. An organization like MSF might end up with all its projects in Congo, Somalia and South Sudan. If the needs are there in NYC or Greece, and let’s say they don’t have to be DRC level, but they can’t be too simple, then I think the decisions are defensible on the grounds of impartiality. The problem for me, though, is whether or not the identification of needs began with an idea that there was a special relationship to some victims, some sufferers, and not to others. Doesn’t that strike you as crossing a line? And remember, I’m fine with a little wink wink crossing of the lines in the interest of the institution (e.g., like publicity in the home market), but let’s not make it a big deal and let’s not actually try to justify it via an appeal to a legitimacy of action as civil society actor.

      1. But Marc, we are civil society actors. Non-governmental, and not for profit, it’s all that’s left – the third sector; civil society R us.

        As a whiskery youth I joined civil society, the National Union of Students, and marched against Apartheid. The first time I voted (in 1979) and irrespective of my vote, Margret Thatcher swept into power and swept away my route to self-expression; she dismantled the unions. There’s no contradiction in my mind that Governmental interference in civil society in the second half of the 20th century was met by the evolution of new global civil society actors – Greenpeace and Amnesty and Friends of the Earth and – yes – MSF.

        My take on the risk you’re referring to is that our revolutionary zeal (as civil society actors) will be deliberately diluted by the system we strive against. By a crafty mix of cooptation, patronage and propaganda, government seeks to regulate non-governmental action. Government actively encourages us to support their agenda – ‘Big Society’ in UK or ‘Force Multipliers’ in US parlance – in order to extend the reach of democracy. Of course, we hate that by exercising our presumed right to take humanitarian action, we end up as tools of the oppressors… but therein lays a whole different discussion, and it’s your blog…

  4. Hello Marc. Another of nice blogs. I enjoyed almost the most. You should be a writer by not only avocation but vocation. Thanks for this one.

  5. Sorry. You are an excellent writer and you should be a writer not only by avocation but vocation. Great blog. Thanks again.

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