The co-construction of medical humanitarianism: analysis of personal, organizationally condoned narratives from an agency website.

Social Science & Medicine xxx (2014) 1e9

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The co-construction of medical humanitarianism: Analysis of personal, organizationally condoned narratives from an agency website Alastair Ager a, *, Melina Iacovou b a b

Mailman School of Public Health, Columbia University, 60 Haven Avenue, New York, NY 10032, USA Barnard College, Columbia University, New York, NY 10027, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 12 December 2013 Received in revised form 23 May 2014 Accepted 29 May 2014 Available online xxx

Recent years have seen significant growth in both the size and profile of the humanitarian sector. However, little research has focused upon the constructions of humanitarian practice negotiated by agencies and their workers that serve to sustain engagement in the face personal challenges and critique of the humanitarian enterprise. This study used the public narrative of 129 website postings by humanitarian workers deployed with the health-focused international humanitarian organization decins Sans Frontie res (MSF) to identify recurrent themes in personal, organizationally-condoned, Me public discourse regarding humanitarian practice. Data represented all eligible postings from a feature on the agency's UK website from May 2002 to April 2012. The text of postings was analysed with respect to emergent themes on an iterative basis. Comprehensive coding of material was achieved through a thematic structure that reflected the core domains of project details, the working environment, characteristics of beneficiaries and recurrent motivational sub-texts. Features of the co-construction of narratives include language serving to neutralize complex political contexts; the specification of barriers as substantive but surmountable; the dominance of the construct of national-international in understanding the operation of teams; intense personal identification with organization values; and the use of resilience as a framing of beneficiary adaptation and perseverance in conditions that e from an external perspective e warrant despair and withdrawal. Recurrent motivational sub-texts include ‘making a difference’ and contrasts with ‘past professional constraints’ and ‘ordinary life back home.’ The prominence of these sub-texts not only highlights key personal agendas but also suggests e notwithstanding policy initiatives regarding stronger contextual rooting and professionalism e continuing organizational emphasis on externality and volunteerism. Overall, postings illustrate a complex co-construction of medical humanitarianism that reflects a negotiated script of personal and organizational understandings adapted to evolving demands of humanitarian engagement. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Humanitarian Construction Motivation National staff Expatriate Organization NGO

1. Introduction The humanitarian sector has grown significantly in size and profile over recent years. It has been estimated that in the order of a quarter of a million people are employed by humanitarian organizations globally (Stoddard et al., 2009). Alongside such issues of shelter, protection, food and nutrition, and water and sanitation, health represents a major focus of intervention in most major humanitarian emergencies (Ager, 2012). Health positions typically

* Corresponding author. E-mail addresses: [email protected] (A. Ager), [email protected] (M. Iacovou).

represent, for example, between 15% and 20% of vacancies advertised on the ReliefWeb site [www.reliefweb.org], the key source of information on vacancies in the humanitarian sector globally. In spite, or potentially as a result, of this growth, there has been increasing critique of humanitarian strategy and the management of the global ‘humanitarian regime’ (Rieff, 2003; Barnett and Weiss, 2008, 2011; Walker and Maxwell, 2009). The potential compromise of humanitarian values as humanitarian assistance has increasingly drawn upon governments e rather than the general public e as the principal source of funding has been a major feature of such critiques. A medical humanitarian organization such as International Medical Corps received nearly 75% of its income through contracts and grants in 2011, for instance (IMC, 2011). Where humanitarian

http://dx.doi.org/10.1016/j.socscimed.2014.05.053 0277-9536/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Ager, A., Iacovou, M., The co-construction of medical humanitarianism: Analysis of personal, organizationally condoned narratives from an agency website, Social Science & Medicine (2014), http://dx.doi.org/10.1016/j.socscimed.2014.05.053

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A. Ager, M. Iacovou / Social Science & Medicine xxx (2014) 1e9

organizations provide services to migrants and other marginalized populations that are the responsibility of the state, there are concerns that this helps build legitimacy for the state's retreat from social responsibilities to such populations (Gottleib et al., 2012). Another common focus of criticism, analogous to common arguments regarding the development sector, is the neo-colonial nature of humanitarian assistance, with expertise largely deployed from high-income to low-income nations. Despite the humanitarian workforce being drawn from an increasingly diverse range of nationalities, there remain concerns that the power of the humanitarian regime resides largely in nations and institutions of the global North. Linked to this is growing recognition of historical failures to build real capacity for crisis management and response in the global South (IFRC, 2013). Such critiques present major challenges to humanitarian organizations in the presentation of their work to others and in their self-understanding (Calhoun, 2008). The core principles of humanitarianism e humanity, neutrality, independence and impartiality e seek to place the work of such organizations outside the bounds of politics and contingency; such critique grounds them within a contested territory of legitimacy, power and pragmatism. It is not only organizations, but the individuals that work with them, that are faced with the challenge of articulating a coherent construction of humanitarianism. In offering protection, relieving suffering and exposing injustice, humanitarian workers fulfill what are widely seen as the highest human goals. However, deployment as a humanitarian worker has been linked to high rates of burnout (Lopes Cardozo et al., 2012; Stoddard et al., 2009). There has also been a notable rise in humanitarians' risk of exposure to violence and abduction (Sheik et al., 2000; Stoddard et al., 2009). In 2008, for instance, the mortality rate of humanitarian aid workers was higher than that of UN peacekeeping troops. This trend is widely seen as representing a loss of the ‘humanitarian space’ that previously saw humanitarian workers protected from harm on the basis of their perceived neutrality and impartiality (de Torrente, 2004). They are now increasingly seen to be professionals undertaking a job, not clearly distinguishable from the contractors deployed to humanitarian contexts working without explicit humanitarian motivation (Abu-Sada, 2012). The construction of humanitarian work e the understandings through which it is given purpose and meaning e is thus of significant relevance to both organizations and the individuals that work within them. It reflects the manner in which sense is imposed upon a complex, contested role at the margins of regular organizational expediency and personal interest. More generally, it reflects the motivations, expectations and norms of humanitarian work that sustain the coordinated actions of agencies and their workers in contexts of humanitarian response. Little systematic research has focused upon workers' constructions of humanitarian practice. The anthology of writings by humanitarian workers compiled by Bergman (2003) remains a key resource, although the growing use of social media has resulted in a number of blogs featuring such accounts (such as AidSource and Humanicontrarian). Redfield (2005, 2006, 2012) has, through an anthropological lens, advanced understanding of humanitarian practice e and the interaction of roles of human rights advocacy and provision of healthcare e with respect particularly to the work decins sans Frontie res. Bjerneld et al. (2006) of the agency Me report on one of the few empirical studies to explicitly address the motivations of expatriate humanitarians in the health field. In pre-deployment interviews, health workers articulated the factors particularly salient in their seeking humanitarian work to include wanting to make a significant social contribution, searching for new experiences, seeking more satisfying work and securing a sense of coherence and community in their work. Sinding et al. (2010)

document the manner in which expatriate medical humanitarians managed competing narratives regarding rights to treatment and scarcity of resources in justifying their decisions to treat, or not to treat, patients in humanitarian and related contexts. Walkup's (1997) analysis of the manner in which ‘burnout’ can be linked to common features of the humanitarian work environment remains one of the most vivid accounts available of construction of humanitarian practice. He emphasizes the manner in which humanitarian discourse can serve to protect humanitarian workers from the ambiguities and incongruities of dealing with large-scale suffering but, over time, may distance workers from beneficiaries. Walkup's work is of particular interest because it is a rare example of explicitly linking the framing of work by the individual humanitarian worker with the scripts provided by the discourse of humanitarian organizations. Work addressing the construction of humanitarian response by organizations has principally taken one of two forms. Some studies have documented the forms of communication which such agencies draw upon in securing public and political engagement , with humanitarian agendas (see Foxx, 1995; Torchin, 2006; Musaro 2011). The recent review of Calain (2013) argued that the use of imagery of suffering bodies by humanitarian agencies “perpetuates a distinct worldview of asymmetrical power relationships, contributing to the ‘humanitarian reduction of the victim' as a passive recipient of aid” (p. 280). Others have examined more broadly the impact of humanitarian response on public discourse. Sorensen (2008), for example, documents how the discourse of humanitarian agencies served to shape the political, cultural and moral landscape in Sri Lanka over many years of humanitarian engagement. Watson (2011) uses the example of the Indian Ocean tsunami of 2004 to demonstrate how the discourse of the humanitarian regime privileged the voices of particular actors and reflected their interests in enabling a securitization agenda. There have been few attempts to explicitly link the constructions of humanitarian workers and their agencies to understand the negotiated space of expectations and norms that determine the day-to-day conceptualization of humanitarian action. This study explicitly addresses discourse negotiated at the intersection of individual humanitarians and the wider interests and perspectives of the agency with which they are deployed. In so doing, it seeks to consider issues of personal motivation and perspective, but in a context that also reflects the perceived legitimate interests and agendas of the agency. A personal diary narrative may reflect the former. An organization policy statement may reflect the latter. The solicited web postings of humanitarian workers on a promotional agency site potentially provide insight into both. Such postings reflect the personal, organizationally-condoned narratives negotiated within an organization. In presenting the discourse negotiated at the intersection of personal experience and organizational interest, they provide insight into the language and meanings deemed legitimate within the organization. As Bergman notes in the preface to her 2003 collection, this is a complex undertaking: some aid agencies were reluctant to cooperate. Others understood that to allow their humanitarian workers a voice was an opportunity to reach potential donors….. [but] in return, they wanted to maintain control of the text (p.12). The study is concerned with the construction of public narratives of medical humanitarianism by workers with the agency decins sans Frontie res (MSF). MSF is not only amongst the Me largest of medical humanitarian organizations, but amongst the most influential on global humanitarian discourse. MSF has been a strong critic of the loss of the distinct role of agencies operating under a humanitarian mandate with the rising co-option of their



work by government actors (Abu-Sada, 2012). It seeks to retain clear independence of government authorities by relying solely upon public donations and generally remaining detached from formal inter-agency coordination processes. Along with relieving suffering through the provision of emergency medical care, the concept of t emoignage e the act of witnessing e is prominent within the formal mandate of the organization (Paulmann, 2013). MSF has been explicit it its attempts to define its purpose and values in the evolving contexts of humanitarian action such as with the collaborative formulation of the La Mancha Agreement (MSF, 2006). This acknowledged many of the forces noted above shaping humanitarian action in the new millennium, as well as the requirement for strategies to protect resources of MSF “being diverted or co-opted for the benefit of parties to conflicts or political agendas” (2.11). It also addressed the demands of MSF operating within a progressively globalized context with the governance challenges of operating with multiple sections. Redfield's work has particularly reflected on the evolving practices within the organization in response to such changes, including the management of increasing diversity and southern stakeholder engagement within the organization and the formalization of systems in an organization still founded on voluntarism (Redfield, 2012). Institutional statements such as the La Mancha Agreement potentially offer very different insights into the understanding of medical humanitarianisms from personal, independent reports of current or former workers, such as the account of motivation and remit provided by Gumbs and Gumbs (2007). The latter will likely reflect assimilation of organizational discourse, but are explicitly centred on personal interpretation and motivation. What of accounts, however, that reflect the negotiation of personal experience within an explicitly organizationally-representative function? This study thus sought to identify common structures in personal, organizationally-condoned, public discourse by humanitarians regarding their work with MSF. 2. Method The data source comprised narratives posted on the public website of MSF UK. These narratives represented all postings on the website over a ten-year period, from the initiation of a ‘Letters from the Field’ feature in May 2002 to the cut-off date for analysis of April 2012. Narratives were presented as personal accounts of workers employed by the agency during the course of their working in a specified humanitarian context. The style of postings varied, but generally followed the form of a diary entry or personal letter, with between 500 and 1000 words of text. They typically featured an account of the humanitarian context, the nature of the work being undertaken, details of specific challenges or achievements and, typically, personal reflection by the worker on their experience in their work role and its relationship to expectations or prior experience. From the total 150 postings in this period, 21 were excluded from analysis on the basis that they did not reflect this standard format of a personal narrative of personnel engaged in health-related activities (e.g. entries involving reposting of interviews of third parties, formal news reports or reflections of journalists). The majority of narratives were authored by expatriate workers, with only 12 postings unambiguously authored by nationals of the country of operations. Table 1 summarizes characteristics of the 129 narratives included in the analysis. Coding was structured by three distinct phases of analysis, using the principles of constant comparative method (CCM) as outlined by Silverman (2012). First, a preliminary coding structure was developed with respect to a sub-sample of 33 narratives. These

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Table 1 Gender, role and Location of profiled humanitarian workers (N ¼ 129). N Gender Role

Location

Female Male Doctor Nurse Other

74 55 32 38 55

Unspecified Africa

4 82

Asia

41

Other

16

including (in order of frequency):

Physician, anaesthetist Nurse, midwife Logistician, coordinator, psychologist, water & sanitation specialist, engineer, head of mission, biomedical scientist, mental health officer, physiotherapist DRC, Sudan/South Sudan, Angola, Chad, Zimbabwe, Ethiopia, Congo, Somalia, Ivory Coast, Sierra Leone, Nigeria, Uganda, Liberia, Kenya, CAR, South Africa, Tunisia Pakistan, Myanmar, Uzbekistan, India, Afghanistan, Bangladesh, Indonesia, Nepal Palestine/oPt, Haiti, Papua New Guinea, Lebanon, Colombia

narratives were sectioned into individual paragraphs of text for review. Two researchers independently grouped sections of text into thematic categories. Each researcher formulated category definitions and sought to saturate defined categories with multiple exemplars from amongst sectioned text. Thematic categories were refined until a coding frame was established that could accommodate all sectioned text. Categories established by these two researchers were then compared, and consolidated into a single coding frame. Second, seven research assistants each produced, independently of each other and the initial researchers, thematic codes suggested by review of five randomly selected narratives. All resulting thematic codes were then reviewed by the two researchers that had originally surveyed the material. Their consolidated coding frame and thematic code definitions were then adjusted to reflect insights and meanings emerging from this secondary analysis. Finally, a third researcher not engaged in this preliminary analysis [the second author] used these thematic coding definitions to code individual paragraphs of text from all 129 narratives. Reflecting the approach of CCM, this resulted in the flexing and elaboration of the preliminary coding frame (specifically, the specification of two additional thematic codes and the revision of two other coding definitions). Such revision was made in collaboration with one of the original researchers [the first author]. 3. Results Fig. 1 presents a graphical representation of the thematic coding structure with respect to which comprehensive coding of material was achieved. It identifies the four core domains emergent across narratives: presentation of project details, the nature of the working environment, characteristics of beneficiaries, and recurrent motivational sub-texts for humanitarians. 3.1. Project details A substantial proportion of text was dedicated to concrete description of the projects with which humanitarians were working. Five major themes were recurrent in such accounts. Narratives frequently began by addressing the context of projects. These were typically presented in terms of external forces shaping the lives of ‘ordinary people’: This peninsula has been inaccessible for 7 years because of the civil war. Sadly, the residents of such small villages in South Kivu have



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Project Details Working with Others

Project Context Services

Barriers

Needs

Working Environment

Beneficiaries

Generous and Kind

Contrasting Conditions

Resilience Inspires

‘Making a Difference’

Contrast with Past Professional Constraints

Role and Identity of Agency

Teamwork, Belonging & Comparative Advantage

Contrast with Ordinary Life Back Home

Recurrent Motivational Sub-texts Fig. 1. Emergent thematic structure derived from 129 narrative website postings by humanitarians between 2002 and 2012.

been terrorised by all the different troops that have passed through, just because they are there. Homes have been pillaged and then burned; women have been raped and men killed These are ordinary people, ordinary families, who have been forced to flee their country due to the unrest. Most have travelled from Homs, where bombs are still falling and clashes between insurgents and the army are rife

We have seen a fair amount of diarrhea and Hepatitis E due to the poor sanitary conditions in the town. We have also seen a number of cases of acute flaccid paralysis, which raised the possibility of polio On the medical side you had the four classical emergencies: displacement, hunger, epidemics and trauma. They are all there in abundance

The identification of victims as those positioned outside of the frame of warring parties not only emphasizes common humanity and the undeserving nature of suffering, but also reinforces the apolitical nature of attribution. When historical and political details of the setting were included, they were often neutralized in some fashion. Below, for example, the term ‘circle of violence’ serves to neutralize attribution for conflict in the occupied Palestinian Territories:

Needs were described in terms of trends and patterns, but were frequently personalized:

The West Bank has experienced its share of violence on both the giving and receiving end. This circle of violence, this ongoing danger, reeks in the atmosphere

Narratives then typically outlined the services developed in response to these needs:

Violence being described as having ‘become a part of everyday life’ can be seen to fulfill a similar function: From the late 80s onwards, clans and sub clans began to develop militias in order to fight for control of Somalia and overthrow the then Prime Minister, Mohammed Siad Barre. This culminated in the ousting of Siad Barre in 1991. When the unifying point for fighting disappeared, clan tensions came to the fore and Somalia descended into chaos. Since then, extreme violence has become a part of everyday life Narratives generally included an analysis of the health needs of the local population, usually with respect to both specific disease risks and the circumstances that have contributed to them: People hadn't had any medical care at all for a long time so a lot of the problems were … .neglect-related, things like malnutrition and tuberculosis

…women who would absolutely not have been able to deliver normally….in this situation in the past … the consequences would have been death, probably of both mother and child The other day I saw a boy with malnutrition, hepatitis, severe anaemia and pneumonia; he was 4 years old, but looked about 2

The other components of the project include STIs, testing pregnant women for HIV so that they can protect their unborn children from the virus, providing anti-retrovirals for those HIVþ people who need it, and treating any infections they may have Apart from providing an all round medical service, MSF has concentrated on reproductive health care with early treatment of sexually acquired infections, daily antenatal and postnatal clinics, education in safe delivery, and facilities for intervention where necessary While response was often described in technical terms, many narratives also displayed explicit ownership of interventions: We also support tuberculosis and malaria treatment programmes Our job was to get the hospital up and running again, both physically in terms of buildings, beds, mattresses, mosquito nets, electricity and water … but also to set up the pharmacy and actually provide medical care



Details were generally provided regarding the barriers encountered in providing such services. These were typically identified either as logistical concerns: The clinic is half a day by bicycle from the nearest hospital and large town. The staff aren't paid; there are no drugs ..not having the right equipment or drugs; not being able to refer patients with cancers that need radiotherapy or chemotherapy; or as constraints in human resource capacity: During the recent conflict most of the hospital staff fled to Brazzaville … those few who remained, to look after the few patients who'd stayed in town and not gone into hiding, were mostly untrained. We are a bit short-staffed today so I spend the next 5 hours helping my colleague to measure the upper left arm of all children under 5 years The manner in which such constraints are conveyed reflects the complex organizational e and personal e balance between recognition of the severe structural challenges in resource-poor, unstable settings and the importance of maintaining a sense of agency and capability amidst such circumstances. In short, these barriers are substantive, but the narratives generally leave little doubt that they can and will be circumvented. Most accounts of project work noted the contribution of others working on the project: We also had the team of national staff who were mainly handling the nutritional centre that we set up for malnourished patients

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work e and, in particular, a strong sense of camaraderie e was widely addressed in narratives: It is kind of tedious, but we have a great team … and it takes a lot to dampen their spirits A happy new year to you! Here, we toasted ‘l’ann ee de la paix’ … as a team we’ve got everything crossed for the population …

… and together we’re pulling out all the stops to try to reach the poor sods who are still out there with nothing For individuals and organization alike, this sense of intense, committed collaboration appears significant in communicating a key character of humanitarian engagement. The national-international construct is again frequently drawn upon in this context: [We have] experienced and dedicated local colleagues, who greatly help with getting the work done The team is fantastic, both national staff and ‘les expetri es’, which makes it much more than a job Reflections on the nature of relationships with national personnel were common (as noted earlier, only a small minority of postings were themselves made by national staff). Constructions of the commitment and capability of such staff were frequently positive: Luckily [I have] experienced and dedicated local colleagues who help greatly with getting the work done

Out total workforce is 156 national staff over the two bases

Thankfully, we five expatriates are just a small fraction of the MSF team here in Shangil

There are over a hundred Sudanese staff - nurses, doctors, pharmacists, midwives, community health workers, guards, drivers, cleaners

I am responsible, with Gregoire, a local nurse, for five health centres… [he] knows a lot more about tropical nursing than me

Roles and professions offer a key basis for categorization of staff, but the construct of national-international is also prominent. Redfield (2012) has noted the differentiation of national (local) and international staff on the basis of mobility and freedom; despite the former increasingly representing the significant majority of MSF workers and despite the intentions of the La Mancha Agreement, there exists a continuing dominance of international (expatriate) worker experience in shaping the organization's identity. Although principally factual in nature, discussions of project details thus suggest a recurring script regarding agency humanitarian engagement. Structural, historical aspects of context may be noted, but response seldom sees strategy as feasibly or appropriately addressing such issues. Rather, ‘neutral’ humanitarian strategies are articulated in terms of service response to specified health needs and the steps needed to overcome major logistical and human capacity constraints in their delivery. Notwithstanding this latter point, working with others e the majority of whom are distinguished as national staff e is most typically addressed in relation to assistance in delivery of services, rather than in longerterm capacity development. 3.2. Working environment Broader issues of the working environment were addressed by many narratives. One major recurrent theme in accounts could be seen to represent an elaboration regarding the issue of working with others: the nature of team-working, its contribution to a strong sense of belonging and understandings of the ‘comparative advantage’ of expatriate staff with regard to national staff. Team-

Such respectful appreciation of national staff capability is consistently presented. However, this script is nuanced with discussions of the comparative advantage of expatriate workers with respect to national staff. Although this sometimes involved discussion of clinical skills, it more often addressed management and organizational capability: The staff were very capable and experienced from a scientific point of view, but lacked some knowledge of stock management and issues such as waste management and health and safety I arrived with a western viewpoint, as was only to be expected, and this jarred somewhat with the staff who were used to doing things in a more relaxed manner. We compromised in that I learned to slow down and they started to take things like quality control more seriously On enquiring of the nurses … about how often the sheets get changed the response ‘never’ wasn't a surprise. The sight of ten sheets on the washing line the next day was. Maybe our enthusiasm is infectious… I was also constantly trying to motivate local staff, and it was a major challenge to encourage them to turn up to their shifts The inclusion of such accounts demonstrates the potential insights offered by a narrative co-constructed by individual and organization. The events described here appear significant in individuals' understanding their contribution as expatriates e outsiders and experts e in shaping services. The organizational condonement of phrases such as ‘I arrived with a western


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viewpoint, as was only to be expected’ suggests strong tolerance for external understandings. Such accounts generally appear to equate ‘a Western perspective’ principally with efficiency, with such efficiency e further e being constructed as a personal characteristic that can be ‘infectious’. This may be contrasted with systemic, structural accounts that might view poor work performance as linked to factors such as insecure employment, irregular payment of wages, poor supportive supervision and inequity in employment practices, all regularly identified as affecting national staff employment in humanitarian response (Maclachlan et al., 2010). The closest to recognition of such factors was in statements such as: Local people are very motivated to help, even though working with an international organization is associated with some risks … many of our staff are recruited in the capital … and have left their families to … work [with us] It took a while to get used to all the HR issues that arise! Maternity leave is very common, the salary scale hopelessly complicated and … employment law has enough clauses to be a full-time job in itself! This is not to suggest that the agency and its expatriate personnel do not recognize the hardships and challenges of working as a national staff member in a humanitarian context. Rather, it is to recognize that the issue of teamwork tends to elicit constructions of role differentiation based upon an individualized, manageriallyfocused discourse rather than a skills or systems discourse. A second recurrent theme in discussion of agency working was strong identification with the organization. Constructions of this typically considered the scale and reach of the agency: I am really proud of the work that MSF is doing. Last year alone, we provided more than 32,000 medical consultations over … three projects in Jonglei, South Sudan MSF now has a total of 44 international staff and over 900 national staff running hospitals, clinics, feeding centres and cholera treatment centres - a regular army The situation here is tough, but it would be a lot tougher if MSF wasn't here. It's not exaggerating to say that, at the moment, we’re really the only hope … Due to the complicated security situation, we’re the only medical organisation still operating in this area of Somalia Some narratives noted more explicitly the values of the organization: We don't take money from any government to work here, which is what allows us to maintain our independence and gives us the freedom to operate

themes regarding personal identification with the humanitarian values of the organization that are more fully developed in a later section of the analysis. A third major theme emerging in discussions of the working environment was the common use made in narratives of stark comparison of conditions with generally ‘Northern’ settings: “Does this happen in your country?” she asks. I'm shaking my head. No. The short answer is no. I could elaborate on this. Of course people die young. Of course people suffer. I could talk about statistics, demographics or philosophy or religion. But I'm talking to a woman who is nursing in a country with one of the lowest life expectancies in the world. The whole world. So, essentially, the answer is no. No, it doesn't happen in my country. It was very upsetting for me as I couldn't help thinking that this just wasn't fair. Despite doing all we could, had she been in a country with better access to immediate healthcare and the medical technology that we are so familiar with in the UK, she would most likely have survived I still find it difficult to deal with the global inequality in access to good health care and the fact that people are dying of diseases and medical problems that would never occur in the UK I was born Greek, in a middle class family that provided a comfortable life for me. But I could just as easily have been one of these children thrown from their home, forced to depend on the kindness of neighbours or relatives to provide food to keep starvation at bay. I'm not one of these children, I was lucky, and now the least I can do is speak out for their right Such narrative elements seek to address the personal and professional experience of gross inequality in outcomes and resources observed between the local context and the ‘home’ of the author. This is realized by varying devices: it is not ‘fair’, for example; or it is down to luck as ‘I could just as easily been one of those children’; or e as in the last example e rights are asserted. There appears to be an important tension being managed here between a recognition of structural factors that determine such gross inequity (and acceptance of the impotence of humanitarian health interventions generally to address these) and the importance e organizationally and personally e of sustaining a sense of purpose in the face of such structural challenges. This device of comparison was not only used by expatriate staff. National staff also adopted it to emphasize the telling nature of the conditions being faced. A doctor born and raised in West Bengal reflected on an area of the state impacted by Cyclone Aila in 2009: The Bengal I knew was concrete buildings and a vibrant middle class society. North 24 Parganas is just the opposite. There people live in mud houses. They represent the lowest economic strata of society

with individual commitment to organizational values a consistent theme: It is thanks to this conviction and our dedicated and talented teams that we are in a position to help the people who are most affected by the ever-changing and highly charged situation Something like 50% of those who volunteer with MSF only do one mission, 50% of the remainder only do two. They say that those who carry on after that point are hooked for life. I certainly am. I can't overemphasize the deep satisfaction I feel working with MSF Such statements can be seen to reflect the promotional intent of the narratives from an agency perspective, but also introduce

3.3. Characteristics of beneficiaries Clearly how beneficiaries are constructed is likely to have strong influence on relationships between humanitarians and the patients and wider community that their project serves. Articulating the needs of beneficiaries has already been addressed in the context of project details. There were two additional themes commonly presented in narratives. Firstly, beneficiaries were regularly depicted as generous and kind: I found the Sudanese to be extremely welcoming, generous and kind. I marveled at the fact that people who had been through so



much e like being displaced from their homes and separated from spouses and children for up to 20 years - could smile and laugh and revel in life Secondly, the resilience of local communities was frequently noted. Such resilience was often characterized as inspiring: Every day I am surprised by something e how resourceful people with so little can be…the kids that beat all the odds and made it to see another day These people have got on with their lives despite what they have been through and that's a real inspiration. You take that home and don't forget it in a hurry Narratives not only emphasized durability but also considered the positive outlook and affect of local populations as having implications for life beyond the crisis setting: My lasting impression will be the positive outlook of the Sierra Leonean people, who have been through such horrific atrocities but somehow remain optimistic and whose smiles I will remember forever I marveled at the fact that people who had been through so much….could smile and laugh and revel in life [People] are happy, are positive. There is no anger over all that happened, no bitter envy of those who live in better conditions. The resilience of the people here is impressive; a strength I much admire The recurrence of such narrative elements confirms the widespread utilization of the idea of resilience to manage complex construction of environments where vulnerability and capacity of beneficiaries needs to be carefully nuanced (Panter-Brick and Leckman, 2013). With respect to a privileged, comfortable, Western perspective e the authorial position assumed by most narratives e resilience appears to provide an acceptable framing of adaptation and perseverance in conditions that warrant despair and withdrawal.

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It was a joy to leave knowing that there was a reasonable chance of a future without fear for the people and that the investment made…would continue to benefit the people And now I have got to run. Try to get to those people that still lie beyond our reach As with all narrative elements, the above text can be read with respect to both an organizational and a personal agenda (the negotiated text reflecting elements of both). For the former, these statements can clearly be understood as promoting a perception of the agency as having impact notwithstanding the challenges and critiques of the humanitarian enterprise. Of rather greater potential interest is the role of such assertions for humanitarian workers themselves, with many of the narratives going beyond reportage of impact to talk of ‘joy’, ‘satisfaction’, ‘reward’ and ‘gratification’. “And now I have got to run….to get to those people that still lie beyond our reach” represents a particularly vivid illustration of presumptive value which, while evocative of commitment, also reflects somewhat narcissistic elements of self-worth. In the calculus of justification of risk, separation from family and other costs of humanitarian service, such constructions of crucial influence are likely of significant importance. 3.4.2. Contrast with past professional constraints Many narratives drew contrasts between past professional experience and current responsibilities, generally suggesting that the latter allowed for a significantly more flexible e and rewarding e work experience: it was an absolutely unforgettable experience and, as a water engineer, a chance to do something really excitingly different I did a series of unfulfilling jobs in London…I was surprised when I was offered a position in South Sudan coordinating [a project]…I barely knew where Sudan was located and understood even less about its history and politics, but I accepted readily By profession I am an adult doctor not a pediatrician and sick children fill me with dread. However, I have become aware that simply being a doctor is enough here ... specialisation is not a factor for these people seeking treatment

3.4. Recurrent motivational sub-texts for humanitarians The final identified domain related to motivational forces that were sub-textually represented in many narratives, frequently connecting other themes. Three principal themes emerged from analysis.

3.4.1. ‘Making a difference’ The importance of having directly contributed to favourable impacts was frequently addressed in the narratives: By the end of my time in DRC we had opened a further two cholera treatment units…when everyone pulls together…we can make a real difference to lots of people One of the most rewarding things was to witness the change in the atmosphere in the village over the course of our stay. When we arrived, people said they didn't have enough energy to fish or get food, and the mood was very low. A week after we started treating people things were much better It was very gratifying to drive past [people]… who a few days before had been near to death [now]…smiling and waving at us I find kala azar an extremely satisfying disease to work on

There is a general celebratory tone of working outside of established ‘comfort zones’, with stretched competencies seen as a source of honour rather than concern: We did a totally crazy transfer today of a guy who had been shot through the neck. The surgeon could put his fingers in one side and out the other! I went to Sierra Leone as a nurse, but soon found that I was given a lot more responsibility than I had ever had in [my home country]. I had to manage the pediatric ward, maternity ward and operating theater. I was also the pharmacist… and in the last two months took over anesthetic duties…since the anesthetist left! Life in the project has a very different rhythm from home…work usually starts around 7.30 am and never really finishes As usual with MSF, my learning curve is beyond vertical The description of long hours and assumption of duties for which one had not been formally trained was consistently presented by workers in terms that reflect positive appraisal of such demands. The apparent organizational condonement of such statements reflects a nuanced dynamic where evidence-based,



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professional practice is increasingly promoted but within a culture that still strongly affirms a volunteer sensibility (MSF, 2006; AbuSada, 2012). 3.4.3. Contrast with “ordinary life” back home In addition to contrasts with past professional life (and the contrasts in conditions shaping needs and resources discussed earlier) narratives frequently drew contrasts with broader elements of ‘ordinary life’. Given the predominance of postings by expatriates, these contrasts drew heavily a sense of home: At the end of February…I left a cold and snowy England to be transplanted into the arid desert soil of Somalia We slept under the stars…beautiful. It makes you very appreciative of what you have when you get back to ‘civilization’. I will never ever take a flushing toilet for granted again Last year I had to get my passport replaced after 18 months of use as it was full…I have seen parts of the world that are closed to many, and I will have those memories forever Narrative elements generally positioned the writer with respect to an imagined home of familiarity, stability, and serenity. The text frequently struck a tone suggestive of a travelogue: For Thai Pongal (New Year's) festival on Monday we went to our logistics assistant's house for festival rice then went to the beach to see loads of children with kites I didn't know until I got there but it's a magical little place. The most beautiful natural setting on hills around a bay, with a lagoon and beach. A great little seaside town - in another time perhaps Been a while since I picked up my pen but unfortunately can't be long as we are about to leave on another venture into the great unknown Exoticism associated with ‘ventures’ appears as an important aspect of the humanitarian experience for many of those working with MSF. For the organization itself, such discourse is potentially more problematic. While it may assist, for the reason noted above, in the recruitment of workers, this post-colonial ‘othering’ of settings potentially reinforces ideologies at odds with strides towards a less Eurocentric and more globalized conceptualization of the agency. 4. Discussion It is appropriate to recognize the limitations of interpretation based upon the study design. This is a study of a single organization and, while some elements of construction of medical humanitarianism identified above may be shared by other agencies and those working with them, generalization beyond MSF would be speculative. Indeed, as the data source was a feature unique to the MSF UK website, generalization to all MSF sections (which differ widely in size, focus and culture) may be unjustified. Further, the narratives featured on the website represent the reflections of a significant minority of MSF workers deployed between 2002 and 2012. The claim for representativeness rests on these being the total sample of those producing posts for the ‘Letters from the Field’ feature over that decade. The analysis of this paper is predicated on the view that these website postings provide unique insight regarding personal, organizationally-condoned, public discourse regarding the work of medical humanitarians. The postings are considered personal to the extent that each narrative presents a clear authorial voice

recounting the experience of an individual humanitarian worker. They are deemed organizationally-condoned to the extent that the narrative e by virtue of its inclusion in the series of postings e was deemed acceptable by the organization. The extent to which the requirement for organizational acceptance shaped production of initial draft text from humanitarians or its subsequent editing by the organization is not known, but is considered immaterial for our purposes. The narratives represent a co-construction of humanitarian work reflecting inputs or expectations of both worker and agency. Further, the postings are recognized as representing public discourse, because this co-construction was done in full knowledge that the resulting narrative would be publicly available as an account of the work of both the humanitarian and the agency. There are clear demand characteristics (e.g. regarding self-presentation, accountability, advocacy etc.) shaping the production of agreed text in such circumstances. However, we share with Silverman (2012) the view that all narratives e whether private diary entries, debriefing interviews with line-managers or researchers, or public commentaries on organizational policy e reflect contextual demands. With this background, website narratives that are coconstructed by workers and the agency are assumed to reflect scripts that structure the everyday practice of medical humanitarianism by the agency and its workers. The construction of the humanitarian enterprise presented by these specific public narratives is considered of particular interest given the mandate of MSF with regard to witnessing e t emoignage e mentioned earlier. For MSF, telling the story of suffering is not incidental to the relief of that suffering but a goal in itself. Much of the common narrative of postings can be read purely from the perspective of the interests of corporate fundraising for the agency. In such terms, the e generally sequential e core script of identifying needs, providing services, overcoming significant challenges and demonstrating impact appears particularly pertinent. Those who have worked with the agency appear to be both capable and willing to narrate their personal experiences within such an organizationally-determined frame. However, in assembling public, organizational narratives from personal testimony, this script is embroidered with numerous sub-texts reflecting more nuanced constructions of humanitarian work. For example, the use of neutralizing phrases (such as ‘circle of violence’) in describing complex, intense political conflicts reflects the daily challenge of MSF work e both in the field and in the public sphere of the media e to operationalize the humanitarian principle of neutrality without ignoring the varied legitimacy and power of combatants. Bearing witness to human rights violations and negotiating with rival militias requires sharp political analysis (Abu-Sada, 2012), but this cannot be articulated in a manner that risks interpretation of partiality. The absence of particular themes may be as instructive regarding the negotiated language of the organization as their presence. The narratives are notably silent on issues of religion, faith and spirituality, especially given their historical and contemporary significance in shaping humanitarian impulse and action (Barnett and Weiss, 2008). The explicit presentation of MSF as a secular organization may result in the recruitment of individuals with a more secular perspective; however, the lack of commentary on faith even as an influence on the resilience of beneficiaries suggests a more general adoption of a ‘secular script’ as a means of avoiding concerns regarding transgression of the key humanitarian principles of impartiality and independence (Ager and Ager, 2011; Abu-Sada, 2012). The construction of the distinction between e and comparative advantages of e expatriate and national staff is another issue that reflects nuanced processes at individual and organizational levels. The work of Redfield (2012) is of relevance here, notably his analysis of ‘the fundamental divide between traveling ex-patriates and



the much larger pool of workers circulating through a local job’ (p. 376). Ager et al. (2012) found issues between expatriate and national staff to be amongst the three most frequently reported chronic stressors for national staff working with humanitarian organizations in northern Uganda. Here we find the specific contribution of expatiates to frequently be understood to reflect organizational skills and ‘work ethic’. Talk of ‘trying to motivate local staff’ generally belied a lack of awareness of how structural factors can undermine work performance in such settings (Maclachlan et al., 2010). Since the La Mancha Agreement, MSF has been working to “to address the under-utilization of human resources and inclusiveness in decision-making” by providing “fair employment opportunities for all staff based on individual competence and commitment rather than mode of entry into the organization (either through national or international contract)” (MSF, 2006; 2.13). In this regard, it is relevant to note that the 12 documented postings by national staff all dated from within the latter half of the review period subsequent to the formulation of the La Mancha Agreement. Reinforcing conclusions of other studies, such as that of Bjerneld et al. (2006) noted earlier, our findings suggest that making a significant social contribution, seeking more satisfying work, and searching for new experiences is a key motivational triad for humanitarian workers. The salience of such factors e in varying configurations e is indeed readily observable in the social media utilized by humanitarian workers referenced earlier. Although these motivations represent key fuel for an organization with a strong emphasis on voluntarism, their construction also presents significant challenges, particularly when combined with issues of externality and expertise. For example, an interest in the exotic may drive a worker towards variety and impermanence, where a sustained commitment to a culture or region may be of greater operational value. Indeed, Redfield (2012) has noted the difficulties of MSF in securing ‘proximity’ e sustained, informed local engagement e amongst its expatriate personnel. Overall, postings illustrate a complex co-construction of medical humanitarianism that reflects a negotiated script of personal and organizational understandings. The assault on humanitarian space, the globalization of the humanitarian system, the interplay of professionalism and voluntarism, and mechanisms of effective engagement with local actors are all challenges faced on a daily basis by humanitarian field staff and organizational leaders seeking to adapt to evolving demands of humanitarian engagement. Surfacing of the tensions and ambiguities in these negotiated scripts can assist a more self- and organizationally-conscious effort towards their resolution. Acknowledgments Wendy Ager served as one of two initial reviewers of narrative material in the context of work on management of stress in humanitarian organizations. References Abu-Sada, C., 2012. In: In the Eyes of Others: How People in Crises Perceive Hudecins Sans Frontie res, manitarian Aid. New York: Doctors Without Borders/Me Humanitarian Outcomes, and NYU Center on International Cooperation. Ager, A., 2012. Health on the move: the impact of forced displacement on health. In: Zetter, R. (Ed.), World Disasters Report: Focus on Forced Migration &

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