Interview:The History of Doctors Without Borders: Interview with Renée Fox

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This April John Hopkins University Press published Renée Fox's new book, Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières. Renée Fox is currently both a Professor Emerita of Sociology and the Annenberg Professor Emerita of the Social Sciences at the University of Pennsylvania. Fox is a member of the American Academy of Arts and Sciences, the American Philosophical Society, and the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Association for the Advancement of Science, and an Honorary Member of Alpha Omega Alpha Honor Medical Society.

Renée Fox’s major teaching and research interests – sociology of medicine, medical research, medical education, and medical ethics – have involved her in first-hand, participant observation-based studies in Continental Europe (particularly in Belgium), in Central Africa (especially in the Democratic Republic of Congo), and in the People’s Republic of China, as well as in the United States. It was during her research that she first learned of French medical organization Médecins Sans Frontières / Doctors Without Borders. In 1994, Fox began an extensive ethnographic study of MSF that would span decades. Her access to MSF was unparalleled. Noted scholar Charles E. Rosenberg described Fox's book as "an extraordinarily insightful study of an extraordinary organization."

In addition to her newest book, Fox has also published Experiment Perilous: Physicians and Patients Facing the Unknown; The Sociology of Medicine: A Participant Observer’s View; Essays in Medical Sociology; In the Belgian Château: The Spirit and Culture of a European Society in an Age of Change; In the Field: A Sociologist’s Journey, and (in co-authorship with Judith P. Swazey), The Courage to Fail: A Social View of Organ Transplants and Dialysis, Spare Parts: Organ Replacement in American Society, and Observing Bioethics. She is a pioneer in her field and an extraordinarily distinguished scholar.

How did you become interested in studying Doctors Without Borders (Médecins Sans Frontières)? When did you first become aware of the organization?

Doctors Without Borders/Médecins Sans Frontières (MSF) was founded in 1971 by a small group of French physicians and medical journalists in connection with their front-line experiences in the Nigerian Civil War in Biafra, and their response to the tragedies and atrocities that they witnessed in that context. Over the course of the period 1959 to 1993, I spent a considerable amount of time in France and in Belgium, engaged in first-hand sociological research on how social, cultural, and historical factors affected clinical medical research and research careers in a a contemporary European society.

By Category

It was because of my presence on the French medical scene that I learned of the existence of MSF soon after it was created. But it was not until 1994 that I made contact with MSF in Brussels, Belgium, where it had established its second section in 1980. By this time, my research had evolved into a study of "Belgium through the windows of its medical laboratories," which in turn had opened on to research that I was conducting in the former Belgian Congo (now the Democratic Republic of Congo). The fact that Africa in general, and the Congo in particular, were major loci of MSF's work played a significant role in my decision to undertake a sociological study of MSF.

You have published a number of books in the Sociology of Medicine. Are there any themes and ideas that connect your previous work to this book on Doctors Without Borders?

The themes that link my book about Doctors Without Borders with my previous work include:

  1. Moral dilemmas that are intrinsic to medicine and its practice.
  2. Medical uncertainty.
  3. The limitations of medical interventions and action.
  4. Latrogenesis: The unintended negative consequences, and especially the harm that can result from even the most competent, well-planned, compassionate, and virtuously motivated medical acts.

In addition, I hoped that my research about and within MSF would bring me closer to dealing with the relationship of disease and sickness to poverty, inequality and social injustice than had characterized my previous work.

What makes Doctors Without Borders unique compared to other medical NGOs?

There are numerous ways in which the ethos and the organization of Doctors Without Borders distinguish it from most other medical NGOS. These include its "culture of debate"; its constant self-scrutiny and self-criticism; its anti-heroic heroism; its participatory democracy; its decentralized structure and processes of decision-making; the degree to which it has maintained the effervescence of a social movement throughout its forty -three year-long history; and some of the ways in which it maintains its independence from governments and partisan political forces -- among which one of the most notable is the fact that more than ninety percent of its overall funding comes from five million private, non-governmental sources.

An important part of the Doctors Without Borders mission is "to witness" human rights violations. What does it mean to witness these crimes? Is Doctors Without Borders able to remain apolitical if it "witnesses"?

"Temoignage" or witnessing is one of MSF's basic principles. Its scope includes speaking out publicly about exclusion from, or inadequate access to health care, as well as about criminal violations of human rights. A recent example of such "witnessing" is the speech before the United Nation's member states delivered by MSF's International President in which she denounced the lethally inadequate international response to the Ebola epidemic in West Africa. The most vigorous form that such witnessing can take is advocacy. Especially in such instances, there is the danger that it may encroach on MSF's principle of political independence, impartiality, and neutrality.

Throughout its history Doctors Without Borders has been managed in a remarkably democratic (perhaps somewhat chaotic) fashion. Is this a strength or weakness of the organization?

During the more than twenty years that I have been observing and reflecting about MSF, I have wondered how, within its "culture of debate," "ideas matter for action," decentralized, participatory democracy framework it is able to achieve the timely consensus that is necessary to make the crucial decisions with which it is continually confronted, and spring into action in a coherent and coordinated way when called upon to do so. I do not feel that I have ever been able to satisfactorily answer this question.

What is especially impressive in this regard is the alacrity with which MSF is able to respond to emergencies. Contributing to their emergency medical response are their ready-to-ship kits with supplies tailored to the specific type of crisis, whether it is a natural disaster, an epidemic, or a violent conflict.

With respect to MSF's overall decision-making what some MSFers refer to as a latent "informal hierarchy" that exists within the organization seems to help to make it more functionally viable -- though its members and their influence are not always easy to identify.

Doctors Without Borders appears to have two different missions, responding to an immediate humanitarian crisis and providing longterm health care in underserved areas. Do these two missions compete with each other? Is Doctors Without Borders better at handling one of these missions better than the other?

There can be tension between these two "missions." In the early phases of MSF's history it specialized in emergency medicine. But when HIV/AIDS emerged as a new, infectious disease that evolved into a pandemic, MSF wrestled with the question of whether it should undertake its treatment. Among the key considerations that it faced in considering this project was the significant allocation of its commitments, personnel, and material resources to the long term care of persons afflicted with this disease that it would involve, and how competent the members of the organization were to deal with this assignment. Once it made the decision to "take on" HIV/AIDS, beginning in South Africa, MSF demonstrated a trail-blazing capacity to successfully apply long-term antiretroviral therapy for the disease in resource-poor contexts. MSF has thereby shown itself to be equally proficient in handling these "two missions."

What has made it possible for Doctors Without Borders to persevere?

Its distinctive culture, its foundational principles and value-commitments, its "social movement" characteristics, the widespread public admiration it has accrued, and the support that it receives from millions of private donors.

How would you recommend using your book in a class? What message do you think your book will best convey to students?

I think that the book could be appropriately and fruitfully used in undergraduate and graduate sociology of medicine and medical anthropology courses, in courses concerned with social movements, in public health and global medicine courses, and in medical school contexts where the intent is to teach about social and cultural aspects of health, illness, medicine, and medical care. It would also be useful as reading for members of organizations engaged in medical humanitarian work, especially in connection with preparing them for field assignments that they are about to undertake.

I hope that the "message" the book conveys about the principles, values, world-view, motivation, and commitments underlying the medical humanitarian action of Doctors Without Borders and its personnel will be edifying for readers, and a source of inspiration for them.