Dr Joanne Liu’s words last Wednesday were every bit as blunt as one would expect from the head of an organisation known for its outspokenness on humanitarian issues, a realm where tongues – and noses – are often held in the service of the suffering.

“If we let this go, as if it was a non-event, we are basically giving a blank cheque to any countries who are at war,” she said of US airstrikes on the Médecins sans Frontières (MSF) hospital in the Afghan city of Kunduz, which killed at least 22 people.

“Our patients burned in their beds; MSF doctors, nurses, and other staff were killed as they worked. Our colleagues had to operate on each other.”

If hospitals were not safeguarded, asked Liu in a speech delivered at the Palais des Nations in Geneva, how could the medical charity work in other conflicts in Syria, South Sudan and Yemen? After all, she added, “even wars have rules”.

MSF’s assertion that the US military committed a war crime in Kunduz and its call for an independent inquiry under the Geneva conventions have not only pitted it against the Pentagon, they have also served to confirm – once again – the medical charity’s reputation for monumental frankness.

In December 1999, when MSF was awarded the Nobel peace prize in recognition of its “pioneering humanitarian work on several continents”, the president of its international council railed against the “enduring indiscriminate bombing” of Chechnya by the Russian army and explained the organisation’s core philosophy.

“Silence has long been confused with neutrality, and has been presented as a necessary condition for humanitarian action,” said Dr James Orbinski in his acceptance speech.

“From its beginning, MSF was created in opposition to this assumption. We are not sure that words can always save lives, but we know that silence can certainly kill.”



Equally pernicious, said Orbinski, were the euphemisms all too frequently deployed to downplay the atrocities that result from political inaction.

“No one calls a rape a complex gynaecological emergency. A rape is a rape, just as a genocide is a genocide. And both are a crime. For MSF, this is the humanitarian act: to seek to relieve suffering, to seek to restore autonomy, to [bear] witness to the truth of injustice and to insist on political responsibility.”

Though it may be more celebrated for its “first in, last out” approach to humanitarianism, neutrality and the duty to bear witness have been the central tenets of the MSF creed since it was established 44 years ago.

The organisation was founded after a group of French doctors who had volunteered with the International Committee of the Red Cross (ICRC) during the Biafran crisis decided that they could not stay silent about the slaughter and hunger they had seen in the breakaway Nigerian province.

Feeling constrained by the ICRC’s way of operating and the abuses perpetrated by the Nigerian army, they joined forces with a pair of journalists to launch an organisation that would “ignore political or religious boundaries and prioritise the welfare of those suffering” – hence Médecins sans Frontières.

Since 1971, it has responded to manmade and natural disasters around the world and today has a staff of 30,000.

In order to guarantee its independence and safeguard its right to speak out, MSF ensures that the overwhelming majority of its funding – 89% – comes from individual donors.

The rest comes from governments and international organisations. In multi-party conflicts where humanitarian assistance is threatened, it uses only private donations to operate.

“The most notable distinction between MSF and the majority of other international NGOs is that it makes a point of being as independent as [it] can from government, financially,” says the Dutch journalist Linda Polman, author of War Games: The Story of Aid and War in Modern Times.

“They themselves can decide where to go, how long to stay, how much to spend and who to help. That’s a choice that other INGOs don’t always have or make.”

Carrying its own chequebook, and so operating free of the increasingly desperate struggle for international humanitarian funding, has enabled MSF to speak its mind in a way that its peers cannot – or would rather not.

But its high-profile interventions have not always been well received by other international NGOs. In 2011, its then international president, Dr Unni Karunakara, urged aid agencies to stop presenting a misleading picture of the famine in Somalia and admit that helping the worst-affected people was almost impossible.

Karunakara pointed out that hardly any agencies were able to work inside the country and castigated other organisations and the media for “glossing over” the reality in order to convince people that simply giving money for food was the answer.

A couple of months later, MSF went further, publishing a book that catalogued the ugly and difficult compromises that aid organisations are forced to make while working in conflicts.

Too often, explained one MSF director at the time, “there is a mystery about what goes on in the humanitarian world behind closed doors, despite the fact that people know there is often a price to pay to help the victims”.

Sadly, says Polman, the move failed to provoke a necessary debate about the realities of humanitarian assistance.

“They were very open about that and very critical of that and invited other INGOs to be as open and as critical as they themselves were,” she says. “But, alas, the book met with a deafening silence.”

According to Sara Pantuliano, director of humanitarian programmes at the Overseas Development Institute, MSF’s ability to speak out so plainly and so often is derived from the fact that its focus is strictly humanitarian rather than developmental.

“Unlike other NGOs, who are multi-mandated and doing a bit of humanitarian and development work, they are very much focused on humanitarian work in its strictest sense: life-saving work,” she says.

“Neutrality is at the core of their identity. They don’t take sides but they do speak out and bear witness to what they see. MSF came out of the ICRC, but it’s different from the ICRC and the Red Cross because they wanted to be able to talk about what they saw in the field.”



Neither Pantuliano nor Polman has been surprised by the strength and directness of MSF’s response to the attack on Kunduz. This is, after all, the same organisation that withdrew from Somalia in 2013 with a bitter and angry broadside against all those who had murdered, assaulted and snatched it staff.

“In choosing to kill, attack, and abduct humanitarian aid workers, these armed groups, and the civilian authorities who tolerate their actions, have sealed the fate of countless lives in Somalia,” said Karunakara.

In December 2014, months into the Ebola crisis that MSF had foretold, his successor sounded similarly exasperated as she tore into the world’s dithering response to the epidemic in parts of west Africa.

“How is it that the international community has left the response to Ebola – now a transnational threat – up to doctors, nurses and charity workers?” asked Liu.

Once again, says Polman, it all comes down to bearing witness.

“That’s what they decided their mission had to be; it’s this whole philosophy that you can’t stop the bleeding if you don’t find the cause of the bleeding. They do see it as their responsibility to point at causes because, in the end, only by taking away the causes can you actually diminish the suffering on this planet.”

But that approach, she adds, does raise the inevitable and intriguing philosophical question that sits, unanswered, at the very heart of humanitarianism.

“There are two sides to that point: either doctors should help anybody blindly without asking any questions at all, or they should point at those responsible and try to take away the causes of the suffering.”

• This article was amended on 15 October to correct a quote from Sara Pantuliano, who described MSF as “multi-mandated” rather than “mass-mandated”, as written in the original version.