"MSF, Finances, and Medical Triage" by Austen Smith
In the famous words of Mother Teresa, “If you can’t feed a hundred people, then feed just one.” This seemingly simple ethical maxim raises a dilemma that is central to humanitarian relief efforts: which one? Given limited human and financial resources, triage—or “the general problem of humanitarian prioritization”—exists at every level of the system. In most relief-oriented non-governmental organizations (NGOs), the highest administrative officers choose which regions of the world to aid, while field workers choose which individuals. Of the many humanitarian aid organizations, we will take Médecins Sans Frontières (MSF), known also as Doctors Without Borders, as a prime example for its nearly exclusive focus on medical aid in the midst of crisis situations. How can MSF ethically choose whom to medically treat when any decision will inevitably result in a large number of deaths? In other words, if we choose to feed just one, then are we sentencing the remaining ninety-nine to death? For MSF, ethical solace seems to lie in the tenets of a simple, life-affirming philosophical foundation; but in order to meet increasing worldwide needs, the humanitarian organization as a business becomes ever more critical.
The issue of triage, like many issues of humanitarian relief efforts, finds its roots in funding and resources. Ideally, with infinite human and financial resources, medical triage would be unnecessary and everyone in need of assistance would be treated immediately. Even a tempered ideal might be possible in regions of relative abundance: everyone would be treated eventually, commensurate with his or her needs. However, MSF is not predicated on abundance but on responding to emergencies across the globe, especially in exigent areas, with the resources it does have.
Through ethnographic accounts in his book Life in Crisis, Peter Redfield portrays MSF’s ethical foundation as a simple moral dictum that saving a life is good. What this tenet of MSF ultimately reflects, however, is the impossibility to save every life that needs saving. MSF specifically attempts to “build a framework for action around an ethic of life, understood medically and cast on a global scale.” MSF believes consistently, if nothing else, in a life-centered and life-affirming philosophy: “the members of MSF share no sure vision of a public good beyond a commitment to the value of life.”
Given limited resources and personnel, however, the group is forced, out of practical necessity, to prioritize. This triage may take the form of choosing one mission over another, or choosing to treat one person over another. Although Redfield admits that the group “has yielded no clear solutions” in the midst of worldwide medical crises, the actions of the group do maintain ethical consistency, in the face of finite resources, on a foundation of human life.
Thomas Weiss, Director of the Ralph Bunche Institute for International Studies, considers the necessary, practical side of humanitarian efforts in his new book, Humanitarian Business. Weiss remarks that in recent years humanitarian aid has grown “as a business” in a strong market economy. On one hand, relief efforts seem to garner considerable support. MSF’s annual volume is approaching $18 billion, over twice what it was in 2000. However, even the marked rise in humanitarian aid does not come close to meeting the needs of all 50 million people who were living under duress or threatened by wars and disasters in 2012. The beginning of the solution, to Weiss, is further development of NGO “image and marketing strategies,” which are essential for success in the expanding global business.
MSF operated in 2010 with a total expenditure of $1.1 billion, the largest of any humanitarian relief NGO. Two characteristics of MSF’s financial strategies are especially noteworthy. Firstly, MSF is committed to choosing intervention sites based solely on its “independent assessment of people’s needs—not political, economic, or religious interests.” Such a policy leads to significant and unpredictable dents in the MSF coffers, as the group can no better predict the timing of acts of genocide than it can that of devastating earthquakes. In order to sustain its operations, then, MSF relies more on continual, monthly donations than it does on sporadic lump sums. Over 90% of MSF’s revenue comes from donations by individuals and private institutions (primarily corporations, trusts, and foundations). MSF devotes 12.3% of its total donation monies to the fundraising efforts that keep the organization afloat (the group saw a surplus of $176 million in 2010). Evidence of MSF’s financial strategies is readily apparent, as the first result in a Google search of “MSF” is a paid advertisement for www.doctorswithoutborders.org/Donate, a site that asks visitors to become a “Monthly Field Partner.”
Because national media hold such influence on mainstream attention and international donations, MSF understands triage as choosing missions based not merely on the degree of crisis and emergency, but also on the lack of support from other sources. As the United Nations (UN) and national media gave particular attention in 2013 to conflicts and natural disasters in countries such as Syria, Sudan, the Democratic Republic of Congo, and the Philippines, MSF launched new campaigns on lesser-reported crises. “Children with tuberculosis must not be neglected” read the headline of a December MSF article, for example, on health threats in Tajikistan. In spite of worldwide humanitarian efforts elsewhere (the total needs in Syria and Sudan alone are estimated to surpass 3 billion USD), MSF expended its resources to diagnose and treat tuberculosis (TB) in central Asia. Jointly with the Ministry of Health of Tajikistan, MSF hosted a symposium titled “Scaling up and improving access to ambulatory and paediatric TB care in Central Asia and Eastern Europe.” Here is a case of MSF’s triage strategy to champion “underreported” crises that have been overshadowed by those in the mainstream news. If the international community can take care of many children in the spotlight, then perhaps MSF does best to turn its attention to a few children sitting in the corner. Its finances may benefit for doing so, as MSF is likely to attract a broader base of regular donors if it can showcase its many and varied international efforts.
Past generations of relief workers, Weiss argues, have never fully abandoned the “Good Samaritan” ideal, or the illusion that NGOs are “free to act as they [see] fit, taking into account only the needs of the populations they [seek] to help, and the limits imposed by their own charters.” The MSF organization seems to be divesting itself of such a view, recognizing that acts of medical triage, whatever their ethical foundation, cannot be isolated from the practicalities of business. Hence, the choices made on individual and regional levels reflect not merely the fundamental principles of a humanitarian organization and sheer medical science, but also the greatly complex social and economic forces that surround every crisis situation.
 Redfield, Peter. 2013. Life in Crisis: The Ethical Journey of Doctors Without Borders. Los Angeles: U of California Press.
 Weiss, Thomas G. 2013. Humanitarian Business. Malden, MA: Polity.
 Médecins Sans Frontières (MSF). 2014. “Financial Information.” Accessed February 19. http://www.doctorswithoutborders.org/about-us/financial-information/?ref=nav-footer
 Médecins Sans Frontières (MSF). 2014. “Donate to Doctors Without Borders.” Accessed February 19. https://donate.doctorswithoutborders.org/monthly.cfm?source=AZD130000S03&utm_source=google&utm_medium=ppc&gclid=CPrt5emo87wCFas-Mgod30sAjg&mpch=ads
 United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA). 2014. “Overview of Global Humanitarian Response 2014.” Accessed February 19. https://docs.unocha.org/sites/dms/CAP/Overview_of_Global_Humanitarian_Response_2014.pdf
 Médecins Sans Frontières (MSF). 2013. “Tajikistan: children with tuberculosis must not be neglected.” Accessed February 19. http://www.msf.org/article/tajikistan-children-tuberculosis-must-not-be-neglected