Doctors Without Borders is renowned for providing medical aid in some of the most challenging emergency zones around the world.
But lately it has been grappling with another kind of challenge: racism within its ranks.
On Feb. 7, the 50-year-old humanitarian giant, which also goes by its French acronym MSF, released to the public an internal report of the measures it's taking to address institutional discrimination and racism.
This comes after current and former staffers reported hundreds of instances of abuse and discrimination to journalists and to a grassroots advocacy group that these MSF staffers had set up over the last two years. Their accusations included racial slurs aimed at local workers of color, segregation between local and international staffs, as well as unequal pay, benefits and opportunity for advancement for local staff and staff of color.
In 2020, MSF had more than 63,000 staffers in 88 countries. The group is best known for sending medical workers to set up medical operations and treat patients in crisis zones around the world. In Ukraine, for example, MSF has been running emergency operations since the Russian invasion began. It is delivering medical supplies, providing water and sanitation support, and helping hospitals cope with a mass influx of casualties.
But more than 90% of MSF's workforce — including doctors, health care workers, logisticians and other support staff — is made up of locals, or "national staff," as MSF calls them.
According to those speaking out, MSF as a whole values its expatriate workers — usually from Europe and North America — more than local ones. The public charges of discrimination against local staffers led to the creation of the MSF report, which was first published internally in December.
But the reaction to MSF's progress report is mixed. Some critics are saying it's a solid start, while others say a lot more should be done.
MSF itself agrees with both assessments: "This process of taking stock shows us where we are now, and how far remains to travel," MSF International's president, Christos Christou, wrote in the introduction of the report. But "deep cultural change," he wrote, is "inherently slow."
Abuse and discrimination reported in a "two-tiered system"
The story broke last September in a bombshell investigation published as a podcast by Reveal from The Center for Investigative Reporting and PRX, and also as an online story by Insider, a news site. Three reporters interviewed about 100 current and former MSF workers in nearly 30 countries about their experiences of racism, mistreatment and inequality in the organization.
"Every single person we spoke to had witnessed or experienced inequality or racism," wrote Mara Kardas-Nelson, one of the reporters, in an email to NPR. "[We can] confidently say that there is a two-tiered system in which foreigners receive much better treatment, in everything from pay to day-to-day workplace respect."
The reporters say that the people they spoke with, some of whom did not want their names to be used, charged that MSF staffers used explicitly racist language against local staff and staff of color. They quoted one African worker who claimed that white colleagues referred to another African staff member as a chimpanzee, gorilla and monkey. These sources also told the reporters that foreign workers, even those with little experience, are given more decision-making power, higher salaries, better benefits and better protection.
Indeed, salaries are a critical point. In 2020, the average cost of an expatriate staffer (salary and benefits) was nearly six times that of the average local worker, according to the Insider report. And while some expats said they lived better in the field than they ever did at home, local workers described having to skip meals just to make ends meet. According to MSF, the pay difference is because many international workers are on short-term assignments with long-term financial commitments, like mortgages, back home — meaning they have more expenses than local workers.
Local workers also told the reporters about how expat staffers scolded them for eating food or drinking water designated for expats. And when the local workers became ill, they claim that they received a lower level of medical care. During the 2014 to 2016 Ebola crisis in Sierra Leone, for example, local staffers who contracted the virus received care in the same clinics where they worked while foreign workers were airlifted out of the country to better hospitals. This is common practice, the reporters say, by international organizations for their expat staff.
"We were able to document the history of this two-tiered workplace [back to MSF's early days]and how MSF has been aware and to a certain extent concerned about this, with few changes, for decades," wrote Kardas-Nelson.
Asked about evacuation procedures, a spokesperson for MSF emailed NPR that evacuations are "complex to organize" and "in some cases, for specific treatments, we support international staff in getting health care and support in their home countries in order to be closer to their family and support networks, as well as to receive follow-up care from their regular health care providers."
Current and former staffers at MSF speak out
The Insider and Reveal investigations are the most in-depth public airing of personal accounts of racism and discrimination at MSF. But it is not the only source.
In the summer of 2020, more than 1,000 current and former MSF staff members, who had been discussing their concerns about discrimination in the organization over WhatsApp, drafted and signed an open letter that accused their leaders of lacking any meaningful commitment to combat racism within the organization.
According to the letter, an official motion to address racial inequity in the organization was "infamously suppressed" in 2017 and replaced by a statement that "failed to acknowledge the full extent to which racism exists throughout our organization." Since then, the letter said, efforts by MSF leadership to tackle racism have been "lackluster at best." It was the first time MSF had been called out in such a public and collective fashion.
The letter demanded immediate changes, including anti-racism training at all levels of the organization, internal audits of hiring processes and a clear roadmap for the "radical re-imagination of our approach to humanitarian action."
"Not only is racism perpetuated within MSF, but it is racism and white supremacy that shape the culture and mindset that still defines our organization: the white European 'expert' and the 'distant other in need,'" the letter read.
Instead, the letter said, MSF should follow the lead of affected individuals and communities, listen to indigenous expertise and act out of solidarity. In other words, they wanted MSF to decolonize their approach to humanitarian aid.
After the letter was widely publicized in 2020, MSF issued a series of statements and commitments to do better. But after a year, the signatories — operating as a grassroots movement under the name "Decolonise MSF" — said there had been no significant improvement.
In a report published last September, Decolonise MSF said that of the 359 current and former staffers who responded to a July survey by the movement, nearly half "perceived no change at all in their immediate teams or the wider MSF movement regarding abuse of power, bullying and discrimination in the last 12 months."
The number of respondents who said they witnessed or experienced abuse or discrimination in the year after the open letter did drop from nearly 72% before July 2020 to 54% in the 12 months after. Still, nearly two-thirds of the respondents thought about leaving their jobs in the last year due to abuse they experienced or witnessed.
Monica Mukerjee was one of the authors of the report, titled "Dignity at MSF." She is a member of Decolonise MSF and is still employed by MSF as a training course organizer. She describes MSF's overall response to the accusations, the open letter and her report as "mixed."
"There's now room to discuss [racism and discrimination at MSF], but in some ways, it's not a complete discussion," says Mukerjee.
For example, she says she received very few replies from MSF leadership after sending out the "Dignity at MSF" report last September. But since then, she and co-author Arnab Majumdar have been invited by a few MSF operational centers to speak about it.
The progress report that MSF released to the public in February is also a "notable" positive step toward greater transparency, says Mukerjee. But she thinks it's missing some key details, such as a clear timeline for implementing change, budget allocations for taskforces, reparations for people who were harmed or an acknowledgment of Decolonise MSF and others who have spoken out.
"There is clearly a crisis of trust," says Mukerjee. "To rebuild trust, people need to feel acknowledged and heard."
What MSF has to say about it
MSF International President Christou told NPR that he read and listened to all of the personal accounts of inequality and racism brought up by the Insider and Reveal and Decolonise MSF reports. And he responded to a letter the authors of the "Dignity at MSF" report sent to him and other leaders of the organization.
"What they want to tell me — that [MSF] needs to change — is something that I and MSF already knew," says Christou. "But when you hear and read all the personal stories of people suffering, no matter if you have heard 50 or 100 of them, all of them are still a shock."
Christou says even before the allegations against MSF were made public last September, MSF had already initiated substantial long-awaited changes, sparked in large part by the calls for racial justice stemming from the death of George Floyd in May 2020.
For example, Christou says MSF developed a set of metrics in 2020 to measure progress toward equality, anti-racism and the decolonization of aid. The categories include representation of people of color and local workers in leadership, more equitable staff benefits and pay, accessible complaint mechanisms, culturally sensitive communication (for example, avoiding exploitative images of people who are suffering, in fundraising campaigns) and others. These are the categories covered in the progress report, which was first published internally in December 2021.
"However, we are still not where we should be," says Christou. "There is a problem of several types of institutional discrimination inside [MSF], and definitely, there is a problem of individual racist behavior in this organization."
The fact that Christou makes a distinction between racism by individuals within the organization and other forms of institutional discrimination is not surprising to Althea-Maria Rivas, an associate professor of development studies at SOAS University of London. Racism is difficult to talk about, she says, and there is a tendency for people to distance themselves from it when it's called out in their space. However, "somebody doesn't get away with an individual act of racism unless the institutional environment allows them impunity for it," says Rivas.
Still, Christou says that MSF is doing "everything possible to make this organization less unfair to its people." The progress report, he says, is evidence of that.
But noticeable progress will take time, he notes. Not only does MSF need to change its policies and structure to become more equitable, he says, but there also need to be cultural shifts. For instance, moving away from a "white savior" mentality — in which outsiders from wealthy countries believe that only they can save poor, affected communities — may be especially difficult for some MSF veterans who have been "parachuting" into places with their expertise for more than 30 years now. A more equitable model, in which management and senior leadership positions are filled with local staff members, would make these veterans less relevant.
"Things are happening," says Christou, "but one year is a very short time for all these changes that need to happen in this organization."
The idea that significant change takes time sounds like an invalid excuse to Indira Govender, a South African doctor who worked for MSF from 2011 to 2014 and is a member of Decolonise MSF. Her husband currently works for MSF as a logistics manager in an HIV/TB project in South Africa.
"COVID made us all change very quickly, and we did it to save lives," says Govender. "I don't think [MSF] has actually figured out what change it wants or whether it truly wants to change things."
For instance, Mukerjee says it's still not clear from the progress report whether MSF plans to abandon its two-tier system that places more value on international staffers than national staffers.
Christou says his vision is for MSF to value all of its staff equally — just as it values the lives of all its patients. However, he's not willing to dismantle the organization's structure overnight and risk bringing its emergency services to a halt.
"MSF is like a plane that's flying," says Christou. "We know it needs repairs, but we cannot bring it down to fix it. We have to repair it while it flies."
It's not just MSF. Are changes in the offing in the global health sector?
MSF is far from alone in its offenses or even its hierarchical system, says Ngozi Cole, one of the reporters who worked on the Reveal podcast. She and Kardas-Nelson met while working for another global health organization in Sierra Leone. Cole was among the group's national staff while Kardas-Nelson was an expatriate staffer.
"That was my first taste of the clear disparities," says Cole.
While Cole says that her experiences didn't rise to the level of abuse that the MSF workers detailed to her, she has found similar attitudes and behaviors throughout the global health sector.
"There is definitely an idea of expat staff being superior to national [staff] and that national staff are not up to the task," says Cole. This attitude is then reflected in the way that organizations treat local staff, including low pay, insufficient benefits and not giving them enough credit for their work or opportunities to advance.
Althea-Maria Rivas, the academic who has been studying racism and development for decades, is heartened to see a lot more aid agencies, including Save the Children, International Rescue Committee and Oxfam, having conversations about these problems. And she hopes that documented claims of abuse, like the ones against MSF, will lead to stronger support within organizations for anti-racism efforts.
And in fact, Mukerjee says that she has friends and colleagues in other aid groups who are using MSF's progress report to advocate for greater transparency on these issues in their own organization.
Rivas agrees with Christou that dismantling a whole system of racism and coloniality takes time, but she says that organizations can implement meaningful change immediately. For example, she says that organizations should make sure that committees tasked with looking into these issues have the resources, funding and support from leadership to promote change.
For MSF, Govender hopes those changes come quickly, before too many people feel compelled to abandon ship because of the racism they've experienced or witnessed.
"That would be a very sad state of affairs because I still believe in the work that MSF does," says Govender. "Its politics are problematic, but its work is still really important, and I don't think there's another organization on a global scale that can do what MSF is doing."
Joanne Lu is a freelance journalist who covers global poverty and inequity. Her work has appeared in The Guardian and on Humanosphere, Global Washington and War Is Boring. Follow her on Twitter: @joannelu.