- About HHR
Olga Shevchenko and Renée C. Fox Health and Human Rights 10/1 Published June 2008
AbstractThe international humanitarian organization, Médecins Sans Frontières (MSF), is strongly committed to principles of universalism, egalitarianism, and equity, in both its internal and external relations. Nevertheless, the organization distinguishes between so-called “national” staff members (those who are indigenous to the countries where MSF projects are located), and “expatriate” staff (those who are involved in projects outside their countries of residence), in certain ways that it has self-critically termed “discriminatory,” “colonialist,” and even “racist.” It has resolved to rem – edy such practices. Through a first-hand case study of MSF activities in Russia, this article demonstrates that the dynamics of the “nationals”/“expatriates” divide is a more complex phenomenon than MSF’s self-accusatory diagnosis implies; that a fuller recognition and utilization of nationals’ local knowledge would mitigate some of the conditions of inequality and inequity that they experience; but that it would not necessarily be desirable to expunge all differences between the two groups of staff. Furthermore, because they are intrinsic to the structure and conditions of international humanitarian action, some of these differences could not easily be eliminated by MSF, or by any other organization engaged in this kind of action.
The renowned international nongovernmental organization, Médecins Sans Frontières (MSF, or Doctors Without Borders), combines medical, humanitarian, witnessing (témoignage), and advocacy action in a distinctive way. Since its creation in 1971, it has evolved from a small, charismatic movement into a large organization made up of 19 sections, with some 25,000 staff members, 20 presidents, 20 directors, and more than 200 board members. It operates in no less than 77 countries, with 365 projects. As emblematically expressed by its name —“sans frontières/without borders” — MSF has from its inception been committed to trans-national, universalistic, and egalitarian values. These values are articulated in the basic principles of its founding Charter and the 1997 Chantilly Document, which interprets and expands it.1 MSF’s foundational values are deemed applicable not only to the way that the organization provides medical care for “the most vulnerable” individuals and populations in critical and catastrophic situations, but also to the “solidarity” of the relations among MSF’s personnel and the “fairness” of their conditions of work. Ideally, MSF’s actions and interactions with both patients and staff are expected to transcend the boundaries of nation and culture and to be “impartial” and “non-discriminatory” with regard to gender, race, ethnicity, religion, politics, social status, or any such particularistic attributes.2 In light of these stated principles, it is striking to note the anomalous, if not contradictory, fact that staff working with MSF projects located in the countries where they reside are called “nationals,” whereas those who are involved in projects situated outside of their countries of residence are called “expatriates,” or “expats,” and sometimes, “internationals.” There is a sense in which this nomenclature runs counter to the organization’s “without borders” vision. In principle, the national identities and loci of persons affiliated with MSF should be superseded by a “borderless” conception of the humanitarian action in which they are engaged, the space where that action is conducted, their involvement in what is called the “associative life” of MSF, and their commitment to its common purpose. It would seem more logical either to define all staff as “international,” or to eliminate the international/national/expatriate terminology altogether. Although there has always been some dissatisfaction within MSF regarding these categories and with the language used to designate them, no steps have ever been taken to alter or abolish them.
During 2005-2006, however, in the course of a prolonged, MSF-wide process of self-examination and debate, issues surrounding the status, roles, opportunities, and treatment of “nationals” became a focus of “collective conscience,” as well as of “fair employment” concern.3 A conference held in Luxembourg on March 8-10, 2006, was a culminating point in this process.4 At the Luxembourg conference, many members of MSF were surprised to discover that the national staff comprised some 22,640 persons and filled 92% of all field positions, compared with only 2,206 expatriate staff, who occupied about 8% of such positions.5 Despite their prevailing numbers, the national staff is not prominent in MSF’s public representations of its activities, or in the popular understanding of how the organization works. More importantly, as some national members of MSF who participated in the Luxembourg conference pointed out, their knowledge and expertise are frequently undervalued within the organization itself. In one of the most poignant moments of the conference, a Liberian physician rose to exclaim, “We too are human beings! We too have an education! We too have experience and can take responsibility!”
Acknowledgment that it was the national staff members “who live and work in the countries of intervention,” who perform “the majority [of the] individual humanitarian acts…central to the work of MSF,” was accompanied at the conference by strong self-criticism for the belatedness of this recognition.6 Self-blame included testimonies to the fact that “while we have access to a certain number of indicators on our expatriates…[w]e have never tried to understand … who our national personnel are, and the nature of their relationship to MSF…. Access to posts of responsibility or associative life has remained marginal for our national colleagues.”7 No more than 1% of the national staff, it was stated, had membership with voting rights in the associative, decision-making structures of MSF. “Our attitude towards our national colleagues is all too often characterized by racism and arrogance, and an extraordinary degree of ignorance,” one of the most senior MSF members declared, and “[o]ur attitude to all kinds of ‘local’ knowledge and expertise is not much better.” “By the way,” she added in an ironic side-comment, “‘expat’ sounding very much like ‘expert’ to some national staff has led to some understandable disappointment.”8 It was agreed at the Luxembourg conference that there was an “urgent need” to address, and provide remedies for, these “issues of discrimination.”
The nationals/expatriates divide and the specter of colonialism
Bridging the internal divisions within the staff of an international humanitarian organization presents a complex challenge. It entails fundamental questions of justice and equity, and of the extent to which the organization is able to live up to its own foundational principles. In addition, it touches upon issues of resource allocation, expertise-sharing, and organizational morale. In our view, the nationals/expatriates problems that MSF is encountering are manifestations of such questions and issues, and they are ones with which other humanitarian organizations that are international in their composition, value-commitments, and outreach are likely to be confronted.
This article constitutes an empirically-based, sociological examination of how these phenomena occur within certain contexts of MSF and of what efforts the organization has made to deal with them. It emanates from the first-hand research on MSF conducted by one of us, Renée C. Fox (RCF), since 1996, centered on the moral dilemmas faced by the organization, its members, and staff as they carry out their humanitarian, witnessing, and advocacy action. Within this framework, it is built around a case study of the manifestations, dynamics, and consequences of the nationals/expatriates phenomenon in the milieu of the personnel who are attached to the medical humanitarian projects run in Russia by MSF-Belgium (MSF-B). MSF-B is one of the organization’s five so-called operational sections with decision-making and policy-shaping powers that pertain to the functioning of MSF’s projects in the field and to its public positions.9
The first waves of observational, interview, and documentary data that underlie our case analysis were collected by the two of us in May-June 2000 and June 2001.10 In subsequent summers of 2002, 2003, and 2004, Olga Shevchenko (OS) expanded and supplemented these data by following up on the initial contacts and conducting additional interviews with the Russian staff of MSF-B and with Russian physicians who took part in MSF-B’s tuberculosis (TB) project.
One of our major reasons for focusing on the situation of MSF personnel in Russia is that it throws into question a set of shared assumptions about the alleged “discriminatory” attitudes and policies to which nationals are subject that surfaced at the Luxembourg meeting — namely that these attitudes and policies are primarily “racist” in origin and “colonialist” or “neocolonialist” in character. Contributing to these assumptions is the fact that, because more than 64% of MSF’s 365 projects, in over 70 countries, are located on the continent of Africa, a large number of the organization’s national staff are black Africans.11 MSF’s significant presence in Africa is largely attributable to the gravity and duration of the conflicts and disasters that this region has continuously experienced since the founding of the organization in 1971. Its humanitarian responsiveness to these catastrophes, however, is also connected with the complex institutional and personal relationships that MSF has to the history of colonialism in Africa. Members of MSF from such countries as Belgium, France, and the United Kingdom, as one of them put it, have “a passion for . . . Africa . . . that comes from our colonial past,” including family ties that connect them with earlier generations of men and women who went to Africa as missionaries, physicians, colonial administrators, or commercial agents. (“I feel like I am marching in their steps in a way,” a Belgian member of MSF told us.) At the same time, they deplore the oppressive aspects of the political regimes that their countries established in their African colonies and what they consider to be some of the colonialist “crimes against humanity” that they committed. This history and the mixture of strong sentiments that it evokes heighten MSF’s aversion to colonial modes of thinking, feeling, and acting and its sensitivity to the ways in which it might be inadvertently prone to them.
In our view, sincere and admirable though this self-criticism might be, it overly identifies the objectionable treatment of nationals with Africa-related colonial prejudice and exploitation. In so doing, it underestimates the full range and complexity of the micro- and macro-challenges that are entailed in the integration of national staff into an international organization operating in as many different societies as MSF does, under circumstances that involve dealing with intricate humanitarian predicaments and crises, which are often accompanied by a variety of risks and dangers. The issues associated with MSF nationals and expatriates and their interrelations in Russia fall outside the orbit of Africa. It is conceivable that the term “colonialist” could be used broadly to describe any sentiments of superiority or paternalistic, domineering tendencies that expatriates might display toward national colleagues and their compatriots. However, this is not precisely what MSF meant in its self-accusatory statements about the “colonialist” and “racist” ways in which it had treated national staff. MSF’s usage of these terms was more specific, semantically and historically. Examining the interrelationships between national and international staff members in a Russian setting, therefore, introduces a number of considerations that the predominant MSF analysis of these problems does not encompass.
MSF-Belgium in Russia: A brief background
The office of MSF-B in Moscow changed locations several times in the course of our fieldwork. When we made our first visit, the office was housed in a dilapidated, two-story building located in the center of the city, where it was inconspicuously tucked away on one of the quiet, crisscrossing lanes behind theKropotkinskaia subway station. Its shabby interior was bustling with activity. MSF staff, both Russian and expatriate (who were not confined to Belgians), were briskly moving through its corridors, dropping by each others’ offices, and engaging in animated discussions. Our arrival on the scene did not capture everyone’s attention, but the Russian employees quickly recognized that one of us (OS) was a fellow Russian. A small group of them drew her into conversation, in Russian, while she was waiting for RCF to make arrangements with the Belgian Head of Mission for the interviews that we would conduct the following day. It was in the context of these fleeting but pointed exchanges with OS that the existence of a divide between nationals and expatriates first became apparent. One of her Russian interlocutors, a young woman who, at the time, worked as an assistant to one of the Project Coordinators, strongly advised OS that our research should rely heavily on the knowledge and perceptions of the Russian MSF personnel. “It’s good that you should speak to everyone,” she said. “[But] the foreigners don’t have a proper grasp of what is going on. They leave, and we are the ones who stay on. You need to talk to us.” With considerable feeling, she then proceeded to identify what she considered to be some of the problems in the organizational structure of the office and in its process of decision-making. These problems were root-causes of the fact that her talents were not being fully utilized or further developed by the organization, she declared. “Eventually, I will have to leave,” she concluded. “I am working towards my MA degree, and there will be no growth for me here.”12
It quickly became apparent that the persons who made up the core group of Russian staff working in the Moscow office were highly qualified in a number of ways. To begin with, they were well educated, at a level that was comparable to, and in some instances surpassed that of, their expatriate colleagues. The amount of education that they had received was associated with certain distinctive features of Russia’s prolonged (and often forced) history of modernization over the course of the 20th century. The country underwent a transformation from a predominantly agrarian to a heavily industrial economy, with a giant military sector; an elaborate educational system was erected, partly to provide trained cadres for this economy. At the time of the Soviet Union’s demise in the early 1990s, the rate of literacy in the country was approaching 100% — a highly unusual statistic for a nation receiving aid.
These Russian staff members also had a considerable amount of what might be termed “cultural capital” that was not completely attributable to their formal education. Many of them could speak and write in French — which, at the time of our first field visit to the Moscow office, was the lingua franca of the entire MSF organization and the native language of the majority of the 16 MSF-B expatriate personnel in Russia.13 (Seven of these expatriates were Belgian, six French, one Spanish, one Dutch, and one Rwandese.) A number of the Russian staff spoke English as well. In addition, they had a cultivated knowledge and appreciation of Russian literature, music, theater, and dance. They also possessed a valuable reservoir of knowledge about everyday life in Moscow, local social networks, and ways in which the local polity and economy worked (and failed to work).
All told, there were 38 Russians employed by MSF-B in Moscow. In addition to six physicians and three nurses, they included persons who held a variety of “assistant” positions (administrative assistant, financial assistant, logistics assistant, informatics assistant, and project coordinator assistant), an archivist, three secretaries, two chauffeurs, seven security guards, two housekeepers, a cook, and several “supervisors.”
The major project that emanated from the Moscow office was a program for the homeless launched by MSF in 1992. It was headed by the Coordinator of the Homeless Project, an expatriate Belgian member of MSF-B. At its inception, when the number of homeless in Moscow was estimated to be some 30,000 persons, the project consisted of emergency medical consultations conducted in Moscow train stations. By the end of the 1990s, the homeless population had grown to more than 100,000 individuals. Most of these homeless persons, as MSF discovered, were men (90%), the majority of whom were law-abiding citizens who were fit to work and were looking for a job. One out of ten of them had a college education, and one out of five, vocational training. As a result of the waves of privatization and housing fraud that had occurred in Russia during the early and mid-1990s, in the wake of the official dissolution of the USSR in 1991 and the social and economic chaos that followed, thousands of people had lost their apartments and ended up on the streets. An estimated 30-40 % of the homeless were ex-prisoners, as a consequence of an old Soviet law that remained in effect, which contained a loophole through which incarcerated individuals could lose their housing registration. Once released, these former prisoners no longer had the right to move back into their apartments. Furthermore, in violation of existing laws, the state did not issue passports to them — documents without which it was legally impossible for them to find a new home, to be employed, or to earn a living. In response to this situation, the MSF project developed into a program that provided preventive and curative health care in free medical, disinfection, and sanitary centers in Moscow.14
It also offered social consultations to help the homeless obtain legal papers, housing, and jobs. In addition, MSF engaged in activities to de-stigmatize the way that the homeless were viewed and referred to by the public and government officials.15 The ultimate goal of this MSF project was to hand over the program that they had created to Moscow municipal authorities and the local Department of Health.
MSF-B also ran two other programs in Russia, in regions of the country outside of Moscow. One was an anti-TB program in the prison colonies of the Kemerovo region of Central Siberia. It was begun in 1995, in Penal Colony 33 and in the prison hospital in Mariinsk, a referral center for prisoners infected with TB, and it was progressively expanded to encompass all the prison colonies in the region. The program was initiated in response to an appeal made to MSF to become involved in the treatment of prisoners with TB. The appeal had come from one Russian physician — a woman with a high-ranking military-medical position in the penal system who was very concerned about the epidemic proportions of TB incidence in the overcrowded Siberian prisons.
Once MSF appeared on the scene and assessed the situation, it launched action. The colony lacked basic necessities. It did not even have sufficient clothing in which to properly bury the prisoners who had died from TB or other conditions. Before treatment could start, MSF-B staff stocked the colony’s warehouse with soap, linens, clothes, and construction materials. After dealing with the dearth of fundamental provisions, MSF launched its medical program. The program included conducting TB screening of prisoners; providing extra food to those under treatment to increase the quantities of calories that they consumed daily; improving sanitary conditions; supplying anti-TB medication; and training the prison medical and nursing staff to implement effective treatment according to a protocol that would allow for epidemiological analysis of outcomes. The latter entailed persuading the local authorities of Kemerovo and the Ministry of Justice to agree to the use of the World Health Organization’s internationally recommended TB control strategy, known as DOTS: Directly Observed Treatment, Short-course. The key element in this protocol is the administration of a short course of chemotherapy to patients whose TB has been diagnosed through sputum microscopy, and who receive quality anti-TB drugs under conditions of direct observation, to ensure that the medications are taken in the right combination, without interruption, and for a sufficient duration of time. In addition, the MSF team was working on extending the TB project to include DOTS treatment for non-prisoner inhabitants of Mariinsk.
In 2000, the Field Coordinator of this “Siberia Project” was a Spanish MSF-B expatriate, under whose aegis the laboratory “team leader” in Mariinsk (a French MSF-B expatriate) and the physician “team leader” in Novokuznetsk (a Belgian MSF-B expatriate) functioned. They, in turn, were responsible for the work carried out by two laboratory technicians in Kemerovo and Novokuznetsk (French and Belgian MSF-B expatriates), by the two nurses in those locales (Dutch and Belgian MSF-B expatriates), and by the physician in Mariinsk (a Rwandese MSF-B expatriate). Twenty-two Russians were employed in Mariinsk, including a pharmacist, an accountant, an administrator, several logisticians, a person who handled public relations, a number of interpreters and chauffeurs, and housekeeping staff. The nine Russians employed by MSF-B in Novokuznetsk consisted of an administrator, a logistician, several interpreters and chauffeurs, and a cook.
The “Caucasus Project,” based in the territory of Chechnya and Dagestan, was the third program operated in Russia by MSF-Belgium.16 It had always functioned under circumstances that involved serious security risks for humanitarian workers, as well as for the people they tried to assist. Two successive wars have been waged in Chechnya in recent times. The First Chechen Campaign took place from 1994 to 1996, when Russian forces attempted to stop Chechnya from seceding from the Russian Federation. The Second Chechen Campaign was initiated in 1999 by an incursion of Russian troops into the area with the stated objectives of quelling the bandits, criminals, separatist rebels, and terrorists in the region, as well as continuing the fight to bring the breakaway republic back under Russian influence and rule. Officially, the conflict between Chechnya and Russia was over in 2000, but insurgent activity continues to this day.
MSF-B’s Caucasus Project centered on providing shelter, food, medical supplies, medical assistance, and psychosocial care to the thousands of internally displaced Chechens in the territory of Chechnya and in Ingushetia, the republic on the northern slopes of the Caucasus that borders Chechnya.17 The life-threatening security problems in this area have included the kidnapping of several members of MSF and other NGOs, and the killing of six members of the International Red Cross.18 These events have led MSF to take the reluctant decision to withdraw all expatriate as well as all Russian personnel from this area and conduct its humanitarian action by what it refers to as a “remote control system of intervention” carried out by Chechens and Ingushs on its behalf.
The nationals/expatriates divide in the Russian setting
Within the Moscow office and the three MSF projects it managed, the relations between expatriates and nationals were structured in certain consistent ways. To begin with, the Russians employed by MSF-B in a wide array of jobs, which ranged from physicians to housekeepers, greatly outnumbered the expatriate staff. All the top-echelon, executive roles, however, were occupied by MSF-B expatriates. The Head of Mission was a Belgian woman. Working directly under her were a Belgian physician, who was the Medical Coordinator of the Mission, the mission’s French Administrator-Finance Officer, and its French Technical Coordinator.18 On the organizational level just below them were the Coordinators of the Homeless, the Siberia, and the Caucasus programs — positions held by a Belgian woman, a Spanish woman, and a Frenchman respectively. No Russian staff member belonged to this top cadre of the organization.
Not only did these formal status differences exist between the expatriate and national personnel, but there also appeared to be a tacit agreement not to include nationals in the bi-weekly meetings of this group of administrator-directors at which updated information was exchanged, planning was done, and decisions were taken. The one exception to this latent “rule” was notable. At the insistence of Lieve V., the Belgian Coordinator of the Homeless Program, Nikolai S. was promoted to the status of a Project Coordinator and invited to attend these meetings.20 Nikolai was a Russian staff member who functioned as the Co-coordinator of the program but had been defined as an “assistant” working under Lieve’s “supervision.” Lieve had waged a veritable one-woman campaign to achieve this, arguing that Nikolai spent more time on the project, had more knowledge of its history and understood its context better than she did, and had a greater ability to skillfully negotiate with national and local political and health officials on its behalf. Lieve continued to be the official signatory of all the financial and other administrative papers associated with the Homeless Program, a responsibility that she did not succeed in persuading her expatriate colleagues that Nikolai was eligible to share.
When OS did a follow-up interview with Nikolai in June 2003, she learned that Lieve had returned to Belgium and had been replaced by a new Belgian Project Coordinator. The Homeless Program was poised to be transferred to a Medical-Social Center, which would be run by the Moscow Department of Health. Its framework had been created by MSF-B in collaboration with the Health Department and a Moscow in-patient clinic. Nikolai, who was still a Coordinator of the program, was in the midst of talking to representatives of the Health Department about the fact that they had left “the social work component” out of the plans for the Center that MSF had proposed to them; he was trying to persuade them to reinstate it by including a few social work positions on the Center’s staff.21 He intended to continue to monitor the activities of the Center, he told OS, and to be of assistance in its operation and its lobbying activity on behalf of the homeless. On the federal level, he was working to normalize the legal status of homeless persons with the help of a deputy of the Russian Duma, who was a human rights advocate. Additionally, he was readying himself to participate in a new project called “Children of the Street,” which he and Lieve had designed together while she was still in Moscow. This program, which in 2003 had just been approved by the headquarters of MSF-B in Brussels, would deal with the psychosocial rehabilitation of the many homeless children on the streets of Moscow. Despite these involvements and the pivotal nature of his role within them, Nikolai’s activities continued to be “supervised” by frequently changing MSF-B expatriates whom he had initiated into the Homeless Program when they first began to work in Moscow.22 This turnover in staff was associated with the fact that MSF policy permits expatriate recruits to sign up for a minimum six-month period of service to a mission, although the organization prefers a commitment of one year or more.
There was still another set of structured differences between the expatriate and national staff that affected their conditions of work. Unlike those for the expatriates, the contracts under which the nationals were employed were drawn up to comply with Russian labor laws and to be in some degree in accord with the local pay scale.23 This meant that, although the salaries that national staff members received exceeded those of many of their compatriots who did not work for MSF, their compensation was significantly less than what their expatriate MSF colleagues were paid for comparable work. Furthermore, nationals’ incomes were entirely dependent on the continuing presence of MSF and its operations in the locale in which they were employed. With relatively rare exceptions — at least at the time that we were conducting our observations and interviews in Russia — nationals were not considered to be potential candidates to obtain MSF positions in other countries and thereby could not join the ranks of the organization’s expatriate personnel.24 Even if MSF had made this opportunity available to them, many of the Russian employees would not have been able to take advantage of it because of their stage of life and their family responsibilities — notably marriage and parenthood.
In a number of cases, however, they were partially compensated for their lack of physical mobility by the opportunities for local employment that MSF helped to arrange for them when the organization exited from a program, or from a region where it had been working. For example, positions at the Medical-Social Center for the care of the homeless, which MSF had transferred to the Moscow Health Department, were opened up to nationals who had worked for MSF. Similarly, in the North Caucasus, when security concerns made it no longer safe for expatriates (or Russians) to work on the scene with internally displaced persons, nationals of Chechen and Ingush origins were engaged to carry on the project.
In order to find employment on their own, some Russian personnel drew on contacts and skills that they had developed while working for MSF — in a number of instances, obtaining positions with other international humanitarian organizations. For example, when MSF’s Siberia Project ended, Marina T., who had worked as an assistant to the Medical Coordinator of the project, joined an international AIDS treatment and prevention organization, which had been founded by two former MSF-Holland expatriates several years earlier. In addition, the Russian nationals felt that they had received other, non-material forms of compensation from their association with MSF, including what one of them described as the “transformative experience” it had been for her to “realize that this kind of [humanitarian] action is possible in our country.”
The disparities that we have identified in the statuses, roles, opportunities, and recognition granted to national, as compared with expatriate personnel, have multiple sources. Some of these originated in explicit policies of MSF-B in Russia and stemmed from the long-term nature of the projects in which the organization was engaged in this setting; others were inadvertent consequences of attitudes and behaviors that were not necessarily intended to produce the results that they did.25
To begin with, MSF’s formal “policy for human resources in the missions” contained stipulations that a mission should not be administered solely by national personnel, and that a national should not occupy the post of Head of Mission. One of the cardinal factors involved here is what is sometimes referred to as the precept of “proximity,” which is of great importance to MSF. It pertains to MSF’s commitment to be “in the field” — that is, for its members to be physically “present” with the “people in precarious situations” whose suffering they are trying to alleviate through hands-on medical care, face-to-face witnessing, and direct action to help them “regain control over their future.”26 The MSF model is not one that envisions expatriates administering projects from a distance, largely from their homeland base, while nationals engage in “front-lines,” in situ field action. Although the personnel who work in the headquarters of the different sections of MSF do not occupy field positions while they are functioning in this capacity, most of them have had prior experience in the field; prestige accrues to those among them who have had a long history of participating in missions.
In the complex process of decision-making that takes place between the field-based mission offices and headquarters offices, “the field” has considerable authority. In this latter connection, RCF had an especially memorable, relevant experience in observing how much self-determining authority expatriate personnel in the field exercised. She was present in the Brussels headquarters of MSF-B when the Head of Mission in the Moscow office, the Coordinator of the Caucasus Project, and several expatriates who were then associated with this program, made a phone call to the Executive Director of MSF-B and the person who headed the East European desk. They stated that they were planning to make an exploratory, day-long trip into the territory of Chechnya in order to examine the guarded checkpoints that had been set up in the area and to assess the security situation. They did not ask permission of Brussels headquarters to do so, nor did the persons in the Brussels office who conversed with them on a speaker-phone express either their approval or disapproval of the venture. Rather, those at headquarters listened attentively to what their colleagues in the field had in mind, consulted a map to trace out the route that this journey would involve, wished their colleagues well, urged them to be careful, and asked only that they call again when they were back in Moscow to signal their safe return.
In principle, then, and in fact, an MSF mission devoid of expatriate personnel on the scene is both inconceivable and unacceptable — except in the face of the kind of security problems that the Caucasus Project later confronted, when MSF humanitarian action could continue only if nationals of certain ethnic origins carried it out. MSF labeled this situation of action without expatriate participation “a remote control system of interventions.” The ironic tinge of this term implies that, however much the willingness of nationals to undertake this action was appreciated and admired, it was nonetheless considered to be an aberration that was only justified by dire circumstances.
The normative proscriptions against nationals’ being the sole administrators of a mission or holding the position of Head of Mission, also have roots in considerations of security. MSF is concerned both about how their occupation of certain positions might endanger national personnel in their own country, and about how nationals’ being cast in these roles might increase the risks to which expatriates are exposed. As the Chantilly Document of principles states, “MSF strives for strict independence from all structures or powers, whether political, religious, economic or other.”27 In order to ensure such independence when MSF is operating in a war environment like that of Chechnya, it may be essential for the Head of Mission to be an expatriate. In contexts where MSF is engaged in long-term, ramifying, “development”-type projects, however, rather than in pure emergency missions, local knowledge and cultural understanding may be more relevant than independence. Yet in these situations, too, MSF’s presence in a country, the circumstances and meaning of that presence, and its medical humanitarian action bring it continually face-to-face, in myriad ways, with the country’s social institutions and cultural groups. By providing material and non-material resources that do not already exist in the recipient society, the MSF mission brings benefits but also poses a potentially threatening challenge to the country’s citizenry — especially to its authorities. Since the humanitarian crises to which MSF responds are usually situations that are not fully recognized or acknowledged by local authorities, this can create political tensions, which may be augmented by MSF’s witnessing and advocacy actions. Thus, according to MSF’s reasoning, if nationals held the key executive-administrative positions in a mission, they could become vulnerable targets of whatever accusatory or menacing behavior its activities might evoke, and unlike their expatriate colleagues, they would not be able to escape from this danger by leaving the mission country.
The measure of protection that this exclusion provides does not come without a cost. The authority assigned to “field experience” in the organization makes certain positions more influential than others, and in what an Executive Director of MSF has termed the “informal hierarchy of authority” that exists within the organization, the opinions of Heads of Mission carry special weight. Thus, the consensus that exists inside of MSF about the injudiciousness of appointing nationals to Head of Mission posts excludes them from a strategic position of considerable decision- and policy-making import.
The protection of nationals is not the only consideration that makes it unlikely that they will be appointed to head a mission. Their family and kinship relations, their place in the social class system, and their ethnic and religious identities can make it difficult for them to be viewed as persons who embody MSF’s principles of “independence,” “impartiality,” and “neutrality.” These concerns are factors even if the nationals are motivated to act in a manner that is not entangled in their particularistic ties and affiliations, or responsive to particularistic pressures. Although it is not expressly stated in any MSF document that we have seen, wariness about how the particularistic networks to which nationals belong might jeopardize the safety of expatriates, as well as their own, and undermine MSF’s organizational image and security, seems to contribute to reservations about assigning them to Head of Mission posts.28
Sending national staff to work in MSF missions outside their native countries raises an additional problem, that of a potential “brain drain.” Opening up opportunities for qualified members of MSF’s national staff to work abroad would at least temporarily subtract them from the pool of health-related professionals in their countries of origin. Since many nationals are members of societies with a low level of medical infrastructure and a concomitant dearth of trained nursing and medical personnel, increasing the chances of nationals’ becoming expatriates might have the ironically adverse effect of further reducing the already insufficient health professional staff in the countries from which they come.29
Another set of factors that have played a role in the disparate treatment of nationals and expatriates, and in the less-than-full integration of nationals into the mission staff, reflect unintended consequences of MSF’s sans frontières outlook. The universalistic convictions on which MSF is founded underlie a tendency throughout the organization to suppose that playing down cultural differences, overlooking them and, if possible, overcoming or dispelling them, constitute desirable modes of surmounting cultural “borders.” These attitudes may partly account for the fact that what is called the “departure preparedness” training that MSF personnel receive before joining a mission usually involves only a negligible amount of information about the culture of the society and region to which they will be traveling. Once expatriate personnel arrive at the mission site, little emphasis is placed on learning about the culture in which the mission is embedded. Furthermore, underlying MSF’s conception of “witnessing” is the implicit assumption that it is a transcendently “culture-less” process, largely due to the first-hand presence of expatriate personnel in the field who, because they come from “elsewhere,” are not encumbered by cultural values and beliefs that affect the objectivity of their in situ perspective and judgment. The extent to which the “non-ideological ideology” of MSF that expatriates bring with them has been influenced by Western European history and values is generally not acknowledged.
A paradoxical outcome of these manifestations of what might be termed a “universalism gloss” is a failure to fully recognize and appreciate the significance of the “cultural competence” that nationals possess with regard to their own society, and what this competence can contribute to the education of expatriates and to the operation of the mission. Those members of the expatriate staff of the MSF-B Moscow program (such as the Coordinator of the Homeless Project, Lieve V., the Medical Coordinator, and the Head of Mission) who had spent extended periods of time in Russia, had made an effort to acquire some fluency in the Russian language, and had immersed themselves both professionally and personally in Russian milieux, acknowledged and valued the cultural competence of their local colleagues. However, this was not as true of some of the expatriates with no prior experience in Russia or Eastern Europe, who had signed up for shorter terms, lived together in shared apartments, and had little contact with Russians outside of work. In addition, in their interviews with us, several of the Russian physicians involved in the care of prisoners infected with TB in the penal colonies of Siberia commented that some of the members of the expatriate MSF medical personnel stationed in Mariinsk had made little effort to visit that colony or to collaborate with the local medical staff. Although one of these physicians praised MSF’s outgoing Medical Coordinator for her involvement with the program, the prisoner-patients, and Russian doctors and nurses, she characterized other expatriates whom she had met in later stages of the program as acting like “tourists” who had “gone through a one-month preparatory course on TB and then tried to give advice to the local doctors.”
The acerbic comment made by this Russian physician is relevant to an intrinsic component of humanitarian action that can sharpen the differences between what expatriates and nationals experience and heighten tension between them. We refer here to the element of paternalism that is inherent to humanitarian aid, precisely because (to use MSF parlance) it entails bringing “assistance to meet the needs of people in crisis.” No matter how sensitively and respectfully that assistance is offered, it implies that its purveyors are providing essential, desirable, and, in certain ways superior human, technical, and material resources and services that the population to whom they are responding do not possess. Furthermore, in this global age, the form that this assistance takes is often shaped and regulated by the standards set forth by international bodies, such as the World Health Organization and the International Monetary Fund, which are also important sources of funding for humanitarian aid. These external standards restrain the extent to which assistance can be attuned to the particular needs and the distinctive culture of specific populations.
The implications of this inherent imbalance are highly significant in a post-colonial setting, but they manifest themselves in Russia as well, albeit in a somewhat different manner. In post-1991 Russia, widespread anxieties over the loss of its superpower status make issues of authority and autonomy as sensitive as they are in a post-colonial milieu. Some of the tensions that accompanied MSF-B’s TB project are illustrative in this respect. The TB program involved relating to local members of the Russian medical profession that had its own long-standing traditions of basic science, medical research, and clinical care, which it considered both competent and modern, and which, in the era of the USSR, it had exported with assurance to other republics of the Soviet Union. Their customary methods of treating TB relied heavily on long hospital stays, costly radiography, regimens of free and individually prescribed medications, and, in cases where these failed, supplementary surgery. In addition, a Soviet TB patient was entitled to a separate apartment, complimentary trips to seaside resorts, and an excuse from work for at least a year. (In the words of a folkloric, medical aphorism of the Soviet era, “A TB patient cries twice — once when he is diagnosed, and once when he is cured.”) With the economic problems and the deterioration of the health care system that the breakup of the Soviet Union brought in its wake, Russia was unable to maintain this TB infrastructure. The dramatic increase in the incidence of TB and the rise of drug-resistant strains required new approaches to treatment and care.30 However, local and national medical authorities were suspicious of the much cheaper and more standardized WHO/DOTS approach that MSF advocated. They also felt professionally threatened by it. These reactions were a source of potential conflict between local and MSF medical personnel, which was more stressful for MSF nationals than expatriates because for nationals, it meant contravening the professional attitudes, experience, and comportment of their own professional community.
A lack of self-confidence on the part of some expatriate staff concerning their ability and readiness to meet the demands of their roles responsibly and well may also have contributed to their difficulties in treating national colleagues as equals. As we have previously indicated, a staff development program did not exist in the MSF-B Moscow office for the Russian personnel — a lack that they felt keenly. But neither was such a program available to expatriate staff members, either before they took up their posts in Russia or once they had arrived in Moscow. An appropriate training program could have helped to better equip personnel for the management and decision-making that their assignments as project directors and coordinators entailed. This training lacuna has roots in MSF’s founding “idea of volunteerism” — a notion that, in the words of the Chantilly Document, carries with it allegiance to “disinterest, attested to by the non-lucrative commitment of volunteers.”31 Careerist motives for becoming associated with MSF and participating in its action, such as trying to advance one’s professional future, are considered to be incompatible with such a disinterested commitment. As a senior member of MSF who was just about to undertake a Head of Mission assignment in an African country suggested to us, MSF’s tendency to avoid organizing staff development training may contribute to the feelings of insecurity that some expatriates experience on the job. These feelings, in turn, may lead them to behave in defensively super-ordinate and exclusionary ways with national colleagues.32
MSF personnel no longer work without financial remuneration, as they did in the organization’s inaugural days, but the precept of “non-lucrative commitment” persists. It shapes the philosophy underlying MSF’s salaries, which are set below those that persons of similar qualifications would earn in comparable positions elsewhere — including positions in other nongovernmental humanitarian organizations such as the Red Cross. This policy and its wellsprings compound the difficulties that MSF faces in determining how to provide the fairest possible salaries for nationals and expatriates while, in the language of the La Mancha Agreement, “preserving the spirit of volunteerism.”33
The case of MSF-B in Russia that we have examined reveals that there is a more complicated dynamic at play in the relationship between MSF “nationals” and “expatriates,” and in the formal and informal kinds of inequality and inequity that exist between them, than the organization’s self-accusatory allegations of “colonialism” and “racism” either identify or explain. In the Russian context, nationals and expatriates do not differ from one another racially, and the conditions and atmosphere surrounding their work are not influenced by a prior history of colonialism. Rather, their relations in this setting appear to reflect and exemplify in microcosm a more general and encompassing sort of structural imbalance in access to knowledge and resources that is part of today’s global condition. Seen in this perspective, our analysis strongly suggests that adequately meeting what MSF has defined as the “urgent need to provide fair employment and opportunities for all staff based on individual competence and commitment” involves far more than altering disparities in the contractual terms on which nationals and expatriates enter the organization.34
MSF-B has launched a number of initiatives aimed at rectifying the inequitable status of its national staff. Some of these were implemented even before the meeting in Luxembourg. For example, MSF-B conducted a detailed self-study of its pool of national staff and surveyed the remuneration practices followed by the other national sections; it has also started a process of facilitating the appointments of nationals to expatriate positions in other countries. However, aspiring to integrate national staff into an international humanitarian organization in a way that gives them parity with expatriate coworkers poses a number of dilemma-ridden challenges. Some of the issues that this entails could be handled through changes in organizational policy and practices, but there are others that appear to be associated with less malleable attributes of humanitarian action, particularly when it is conducted on a wide-ranging, international scale.
It would not be realistic to assume that all differences between nationals and expatriates could be dispelled, nor would it be desirable to eliminate all of them, even if this were possible. Although continuous vigilance about the insidious forms in which colonialist or racist attitudes can infiltrate expatriate/national relations may be called for, it should not be supposed that acknowledging some of the ways in which national and expatriate staff differ, socially and culturally, is necessarily a violation of universalistic principles, a sign of prejudice, or an invitation to discriminatory behavior. Quite to the contrary, as the MSF-in-Russia case demonstrates, failure to adequately recognize certain of the distinctive characteristics and assets of a national staff — especially their social, cultural, historical, and contextual knowledge of the terrain in which the organization is conducting its humanitarian work — can be a manifestation of a form of inequality. (This was a failing that was quasi-institutionalized inside the MSF-B Moscow mission.) A greater, more appreciative awareness on the part of expatriates about what their national colleagues could teach them, accompanied by organized efforts to learn from them, would contribute not only to a more interactive sort of equality in their relations, but also to the cultural competence with which field projects are undertaken and carried out. In turn, this could eventuate in a recasting and an expansion of the roles of both national and expatriate staff. In addition to being viewed as providers of functionally specific technical assistance, nationals would be valued as expert sources of knowledge, and of ways of seeing and doing, which culturally perspicacious, international humanitarian work ideally requires. Expatriates would not only supply a unidirectional flow of service; they would also be recipients of knowledge transmitted to them by nationals. Such reciprocity could reduce at least a modicum of the structural paternalism that is an indwelling constituent of humanitarian action.
However, the kind of appreciation of differences that we describe, which promotes the development of greater equality between nationals and expatriates, cannot be dissociated from the fact that there are components of humanitarian action that may call for the maintenance of certain differences between the two sets of humanitarian workers, which are less unifying, and less likely to foster equality. One of the most strategic examples of these sorts of distinctions stems from the differential risks that humanitarian interventions involve. Individuals who reside in the countries where humanitarian action takes place are better positioned to navigate the complexities of the national, political, and cultural situation; they are also, however, more vulnerable to the fallout that the organization’s actions may trigger and less likely to escape the consequences of such a fallout. Their undertaking the same risks as foreign nationals do (even if they were to receive the same compensation) might disproportionately endanger them. Moreover, striving to treat nationals and expatriates as identically as possible in every respect could undermine the value of having a nationally and culturally mixed staff on the ground. Such a literal and homogenous conception of equality runs the risk of attenuating differences that matter.
In our view, the insights that have emerged from reflection on the case of MSF-B’s operations in Russia are not only relevant to this particular mission and its societal context, or uniquely pertinent to MSF. They seem to us to be applicable to the challenges that most humanitarian organizations engaged in first-hand “overseas” action face in trying to incorporate local knowledge and expertise into programs that are generally structured and run by what MSF calls “expatriates,” while striving to fulfill the ideals of fairness and equality in their internal, as well as their external relations. Even when an organization has full freedom to define the nature and range of the projects that it wishes to implement on the ground, and is wholeheartedly committed to including local personnel in its operations, difficulties remain, in part because the moral imperative to treat employees fairly — recognizing their unique strengths and respecting their limitations — does not automatically contribute to their formal equality within the organization. At times, it may even run counter to it.
The “good news” in this seemingly pessimistic conclusion is that the persistence of these problems of equality and equity is not always a sign of colonialist or racial prejudice. The “bad news” is that, because some of these problems are intrinsic to the structure and conditions of international humanitarian action, it is probably utopian to imagine that they can ever be eliminated or completely overcome.
The research on which this article is based is part of an ongoing sociological study of Médecins Sans Frontières, which centers on moral dilemmas associated with medical humanitarian action. This research project has been supported by grants made to Renée C. Fox by The Acadia Institute, the Honorable Walter H. Annenberg Chair in the Social Sciences Research Fund at the University of Pennsylvania, and the Andrew W. Mellon Foundation in the United States, and from the Nuffield Foundation in the United Kingdom. The authors are grateful to Christopher Marcisz, Judith P. Swazey, Susan Chambré, Tomasine Kushner, Eric Goemaere, Ulrike von Pilar, and an anonymous reviewer for their thoughtful comments on this article, from which we have greatly benefited.
1. Médecins Sans Frontières, Chantilly Document (1997). The text of the Chantilly Document is available upon request from Doctors Without Borders/ Médecins Sans Frontières, 333 Seventh Avenue, 2nd floor, New York, NY 10001.
2. For more on the origins, history, and structure of MSF, as well as the dilemmas that arise in the course of its humanitarian work, see P. Dauvin and J. Siméant, Le Travail Humanitaire: Les Acteurs des ONG, du Siège au Terrain (Paris: Presse de la Foundation Nationale des Sciences Politiques, 2002); R. C. Fox, “Medical Humanitarianism and Human Rights: Reflections on Doctors Without Borders and Doctors of the World,” Social Science & Medicine 41/12 (1995): pp. 1607-1616; P. Redfield, “Doctors, Borders, and Life in Crisis,” Cultural Anthropology 20/3 (2005): pp. 328-361; P. Redfield, “A Less Modest Witness: Collective Advocacy and Motivated Truth in a Medical Humanitarian Movement,” American Ethnologist 33/1 (2006): pp. 3-26; F. Terry, Condemned to Repeat?: The Paradox of Humanitarian Action (Ithaca, NY: Cornell University Press, 2002); O. Weber, French Doctors: Les 25 ans d’épopée des hommes et des femmes qui ont inventé la médecine humanitaire (Paris: Robert Laffont, 1995).
3. This process of organizational self-examination, initiated in November 2004, resulted in the drafting of the so-called “La Mancha Agreement,” which was approved by the International Council of MSF in Athens on June 25, 2006. The Agreement was intended to be “complementary to the Charter and the Chantilly Principles.” The name “La Mancha” was given not only to the Agreement, but also to the entire process of self-scrutiny, self-criticism, and debate from which it resulted. “La Mancha” intentionally connected the organization and its members with the chivalrous escapades and battles of Don Quixote, the hero of Cervantes’ romance. As such, it expressed both MSF’s ardent dedication to humanitarian ideals and its characteristic self-directed and ironic wit about the exalted nature of those ideals, as well as its supposed nobility in pursuing them.
4. RCF was an observer at this meeting.
5. Although nationals make up such a huge percentage of MSF’s personnel, compared to the number of expatriates, the total funds spent by the organization to cover the salaries, transportation, per diem expenses, and other forms of support for the nationals roughly equal the entire amount spent on compensation for the expatriates. This suggests that, taken as a whole, the international volunteers “cost” on average about 10 times as much as do local employees — a detail that no doubt introduces additional complexity to MSF’s efforts to achieve equity for the latter.
6. This is excerpted from Article 1.3 of the La Mancha Agreement. As in the case of the Chantilly Document, the text of the La Mancha Agreement can be obtained from MSF on request. See note 1.
7. M. Buisssonnière, “La Mancha Here We Come!” La Mancha Gazette (MSF Internal Newsletter, May 2006): pp. 2-3.
8. U. von Pilar, “Sharing Knowledge! The La Mancha Training Center,” La Mancha Gazette (MSF Internal Newsletter, May 2006): p. 12.
9. Along with MSF-Belgium, the operational sections of MSF include MSF-France, MSF-Holland, MSF-Spain, and MSF-Switzerland. The other 14 sections of MSF are called “partner” sections. Their primary functions are recruiting MSF personnel, raising funds, and disseminating information about MSF’s mission and action.
10. Our interviews and observations were conducted primarily in the MSF-Belgium office, with shorter field trips paid to the Moscow offices of MSF-Holland, MSF-France, and MSF-Switzerland, and also to the office of Doctors of the World in St. Petersburg. While we drew both implicitly and explicitly on information and insights gathered in all these locations, the MSF-Belgium mission in Moscow was the primary source of our ethnographic data.
11. African societies number among the top 10 countries in which MSF has invested the largest amounts of operational funds; in 2004, Sudan, the Democratic Republic of Congo, and Angola alone absorbed more than 34% of MSF’s operational expenses.
12. To protect the anonymity of our field informants, we quote their observations here and at several other points without detailed attribution.
13. Although MSF does not have, and has never had, an official common language, English has gradually supplanted French as the lingua franca of the organization.
14. The most common medical problems affecting the Moscow homeless were trophic ulcers and infected wounds, due to exposure to the elements, poor living conditions, and lack of access to medical care. One of the significant results of the care delivered by MSF was to drastically reduce the incidence of lice and scabies among the homeless persons treated.
15. The Russian acronym “BOMJ” is a pejorative term that has been widely used in Russia to refer to the homeless. The term originated in police reports and made its way into wider, everyday usage. Literally, it means “without a fixed place of residence,” but in colloquial language, it carries the connotations that homeless persons are vagabonds, beggars, robbers, criminals, dirty disease spreaders, and “good-for-nothings” who deserve their lot. MSF has achieved a certain success in reducing the frequency with which “BOMJ” is used in official and public Moscow contexts, and in furthering its replacement by the neutral word “bezdomnyi,” which simply means “homeless.”
16. MSF-Holland and MSF-Switzerland have operated more extensive programs in this North Caucasus region than MSF-Belgium.
17. In terms of gravity and scope, military operations in Chechnya fully deserve to be classified as wars. However, because the conflict was internal to Russia, those displaced by it were not granted the status of war refugees and thus had no access to whatever rights and privileges this status entailed.
18. The two most publicized kidnappings of MSF personnel have been those of Kenneth Gluck and Arjan Erkel. Gluck, a US citizen associated with MSF-Holland, was working as Head of its North Caucasus program. He was abducted on January 9, 2001, while traveling in a humanitarian convoy near the village of Starye Atagi in Chechnya, and released on February 3, 2002. Erkel, a Dutchman, was Head of MSF-Switzerland’s mission in Dagestan when he was abducted in Makhachkala on August 12, 2002, by gunmen who kept him in captivity until April 11, 2004.
19. At the time of our field visits to the Moscow office, women filled all three of these positions. We found no evidence in the Russian context or in any other MSF milieu with which we have had contact, that any discrimination on the basis of gender exists. Furthermore, MSF membership as a whole seems to be equally divided between women and men.
20. Lieve V. and Nikolai S. are pseudonyms, as are all the names used in this article.
21. Nikolai attributed this oversight to the Health Department bureaucrats’ lack of familiarity with social work, which was a relatively new profession in Russia. He also pointed to their uncertainty about how to handle the fact that, from an administrative point of view, social workers would have to report to a different set of people and be paid from a different budget source. Instead of confronting and resolving these problems, they simply dropped social workers from their list of personnel for the Medical-Social Center.
22. Nikolai never broached the topic of these persistent disparities in his status-role with us.
23. The formulas used by MSF to arrive at salary figures for the local staff are quite intricate and include, among other things, a detailed assessment of the complexity and responsibilities of the jobs, the number of supervisory responsibilities the positions entail, and the salaries offered for comparable services by employers other than MSF in the countries where they are working.
24. The situation is changing as more nationals become expatriates and as awareness grows within the organization that (in the words of an MSF-Holland member) “national staff . . . are well positioned to manage expats, and especially nervous new young doctors.” Nevertheless, the transfer of national staff members to expatriate positions and assignments is still limited and most often seems to occur when a national of one African country is sent to an MSF mission in another African country.
25. In the earliest years of its history, MSF was principally engaged in relatively short-term, emergency missions in which they responded with immediacy to critical situations due to armed conflict or natural disasters. In a second phase of its history, MSF became involved in dealing in a more sustained way with the predicaments of internally displaced persons and refugees. At present, they continue to carry out both of these kinds of humanitarian action. Increasingly, however, MSF is also undertaking more long-term, development-oriented projects, such as those in Russia, under circumstances that they describe in their La Mancha Agreement as “crises with medical consequences that are not armed conflicts, but can often be . . . catastrophic” — situations in which the “numbers of people affected and the type of specialized care required . . . has been beyond the capacity of local health structures.” A major precipitant of this shift in MSF’s work is the emergence of “new” and “old” infectious diseases on an epidemic and global scale since the last quarter of the twentieth century. Among such diseases, HIV/AIDS, TB, and their concomitance figure prominently.
26. Chantilly Document (see note 1).
28. The problems and dangers that particularistic relations can pose for MSF are especially serious in societal settings where primordial, violence-accompanied conflict exists among clans, tribes, and ethnic and/or religious groups. These dangers also exist in societies where power is held by fundamentalist political regimes that autocratically and militantly enforce beliefs, thought, structures, and behavior on the basis of religion, gender, kinship, and tribal and ethnic affiliation.
29. This trend has two potential repercussions. On the one hand, it could augment the already grave deficit of health professionals and facilitate their migration from the countries where they received their education. On the other hand, by confining their mobility to assignments within the African continent, it may provide a counterweight to what a Joint Learning Initiative report identifies as the “fatal flow” of nurses and doctors from poor African countries to Europe and North America. See C. W. Dugger, “Africa Needs a Million More Health Care Workers, Report Says,” The New York Times (November 26, 2004): p. A27.
30. Russia ranks 11th among the world’s 22 countries with a high tuberculosis burden. Rates of tuberculosis have always been high in the countries that made up the Soviet Union. However, whereas before 1990, the incidence of TB in Russia was gradually declining, since 1992, it has been on a sharp upward trend. Russia’s epidemic of drug-resistant tuberculosis is considered to be one of the worst in the world.
31. Chantilly Document (see note 1).
32. Influenced in part by MSF-Holland, which has always stressed the importance of a comprehensive staff development program and policy, other sections of MSF have been incrementally moving in that direction.
33. La Mancha Agreement (see note 6).
34. Ibid. (Article 2.13).