"From our earlier interventions in Bosnia, Rwanda, Chechnya and elsewhere through to the situations we currently face in Syria, Yemen, South Sudan and the Mediterranean Sea today, MSF has borne witness to some of humanity’s worst catastrophes over the past 45 years. This carries responsibilities."
- Read this article, and others on the topic of Speaking Out, in the Spring 2017 edition of Dispatches, the MSF Canada Magazine
By Stephen Cornish, Executive Director of Doctors Without Borders/Médecins Sans Frontières (MSF) Canada.
“We are not sure that words can save lives, but we know that silence can certainly kill."
These words, spoken by Canadian physician Dr. James Orbinski when he accepted the Nobel Peace Prize on behalf of Doctors Without Borders/Médecins Sans Frontières (MSF) in 1999, remind us of our responsibilities as humanitarians to bear witness to human suffering wherever we encounter it, and to give voice to those affected by it.
MSF field workers deliver emergency care in accordance with our core principles of impartiality, independence and the medical ethic of doing no harm. But by bringing assistance to people affected by brutality and deliberate neglect, we often become direct witnesses to acts of inhumanity.
From our earlier interventions in Bosnia, Rwanda, Chechnya and elsewhere through to the situations we currently face in Syria, Yemen, South Sudan and the Mediterranean Sea today, MSF has borne witness to some of humanity’s worst catastrophes over the past 45 years.
This carries responsibilities. “Humanitarianism occurs where the political has failed or is in crisis,” said Dr. Orbinski. “We act … firstly to relieve the inhuman suffering of failure.” When our ability to act comes under attack, “we will speak out to push the political to assume its inescapable responsibility.”
Témoignage, or bearing witness, is described in MSF’s official statement of principles, known as the Chantilly document, as something vital to our identity — to be “done with the intention of improving the situation for populations in danger,” and expressed by being close to our patients not only to deliver medical care, but also simply to be “near and listening.” But témoignage also comes with an obligation to raise public awareness about what we see, including openly criticizing and denouncing any violations of international humanitarian law that contribute to the suffering we are confronted with in our medical work.
In the Chantilly text, this imperative seems clear. But putting principles into action can be torturously difficult. Speaking out often carries significant risks: to our patients, to our staff and to our organization itself, which can be polarized by the fractious de- bates these serious ethical dilemmas elicit. Témoignage may be enshrined in MSF’s statement of principles, but only as an “integral complement” to our core purpose of “medical action first.” MSF’s history is thus full of examples where our voice was muted due to the fear of expulsion — and the potential loss of access to our patients and populations in danger that entails. We have also purposefully yet painfully decided to leave some settings where our independent medical activities have been blocked, or where we feared our presence could be seen as complicit, manipulated or doing more harm than good.
When should MSF speak out?
How do we decide when to speak and when to hold our tongues? When does bearing witness allow us to stand up for vulnerable people, and when does it place them at risk? And whose voice should be heard? Do we stay to accompany and care for our patients in silence, or do we risk speaking out in the hope of having a greater positive impact on the lives of people in need?
It is seldom easy to chart a course through these ethical dilemmas. Often when we forcefully use our voice as MSF, we are challenged by those who claim we have lost our neutrality, that we are taking sides. Whenever we have called out violations of humanitarian law, there have always been journalists, politicians and sometimes our own donors who question our judgment.
We are not perfect. Decisions made amid rapidly evolving situations will always be based on incomplete knowledge. That is why we continue to debate, analyze and reassess our positions and our historical choices after the fact in the public sphere. But even as we acknowledge our limitations, we must not lose touch with fundamental humanitarian principles when we are confronted with acts of deliberate inhumanity. Neither can we absolve ourselves of our responsibilities.
Delivering humanitarian medical care means going to where the needs are greatest, including those places where parties to entrenched conflicts don’t necessarily welcome our insistence on treating all people who need our help, regardless of identity, race, religion or political affiliation. It also means accompanying people in their times of greatest need, bearing witness to their suffering and its causes, and placing trust in our medical ethics and action.
Speaking out is never an easy decision. But nothing crucial ever is. As long as we remain guided not only by our best available knowledge, but also by our humanitarian values, we will continue to put ourselves on the line and take a stand for what we believe in. We must ensure that persecution and suffering don’t remain hidden from view, and that the voices of all who need our assistance can be heard.
The dilemmas of speaking out: A Syrian case study
This article by MSF Canada Executive Director Stephen Cornish appears in the Spring 2017 issue of Dispatches, the MSF Canada magazine.
In the six years since the war in Syria began, Doctors Without Borders/Médecins Sans Frontières (MSF) has steadily lost access to patients in many parts of the embattled country. The government has declared that providing treatment to opponents of the regime amounts to terrorism under Syrian law, and has forbidden MSF from accessing many of the war’s victims who need our help most.
In some areas outside of government control, MSF can provide direct care; in other parts of Syria, we can only offer support from afar. In the earlier days of the conflict, MSF often chose pragmatic medical action over témoignage. In places we couldn’t work directly, we delivered vital medical supplies and training, and provided doctors on the ground with crucial structure and support. These physicians and their colleagues formed our trusted networks inside the parts of the country we couldn’t reach with permanent external presence. They were our lifesaving arms in the hardest to reach locations, and through their medical work became our eyes and ears on the ground, informing MSF of the types of cases they were seeing, and providing critical medical data on the health status of the populations in their areas.
Sometimes these reports included medical evidence suggesting patients had been victims of chemical-weapon attacks. Such isolated accounts were disturbing, but extremely difficult to confirm. They also could not prepare us for the magnitude of what was to come. I was in the region with MSF teams when, on August 21, 2013, three MSF-supported hospitals in the Damascus area reported receiving close to 3,600 patients within a span of three hours, all displaying the devastating neurotoxic symptoms indicating the use of chemical weapons.
A chemical attack of such size on civilians is a mockery of the rules of war, and of all MSF believes in. If the reports were true, we had a responsibility to tell the world. Our information was second-hand, but came from our trusted medical colleagues. The risks and implications, however, were enormous, including the possibility our témoignage could be exploited by opposing sides in the war. We had no way of knowing who was responsible for what our teams were seeing. But the use of chemical weapons was also one of the “red lines” the United States said would compel it to take direct military action in Syria’s war.
Would speaking out result in US missiles raining down on Syrian cities? Would it cause reprisals against our doctors inside Syria, and our expulsion from places where we were directly providing care? On the other hand, how could we allow ourselves to keep quiet when our medical colleagues were apparently witness to an atrocity that the rules of war were meant to protect humanity from in the first place? Would remaining silent make us complicit in the horror unfolding and allow it to be repeated in other places?
In the end, MSF decided to go public with our evidence, which corroborated the use of chemical weapons in Syria’s war, and we made clear the source of our information. The US did not use it as a pretext for military involvement, but our testimony was seen by some as a denunciation of the Syrian regime.
Did we do the right thing? Only history can judge. We were accused by some of com- promising our neutrality, but we stood by the accounts of our medical colleagues and our decision to bear witness to reprehensible acts against civilians in Syria.
In real time there is seldom a clear division between right or wrong, no certainty and no clear road to follow. Only a gut feeling, a complex moral duality, a mix of anxiety and the awareness of a deeply abnormal situation of suffering.
In these instances, we must remain guided by the best knowledge we can gather and a willingness to re-evaluate in the face of new evidence. But above all, we must find the courage to adhere to our fundamental humanitarian values, and continue to stand up and be heard when confronted with violations of international law, ethics and basic human decency.
Stephen Cornish is the executive director of Doctors Without Borders/Médecins Sans Frontières (MSF) Canada