Book Review: Peter Redfield, “Life in Crisis: The Ethical Journey of Doctors Without Borders”

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Humanitarian action has attracted increased anthropological interest in the past decade. Life in Crisis is a significant addition to this literature: the first book-length ethnographic monograph of a medical humanitarian non-governmental

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   " Book Review: Peter Redfield “Life in Crisis: The Ethical Journey of Doctors Without Borders” University of California Press, Berkley, 2013, 298 pp Darryl Stellmach, Institute of Social and Cultural Anthropology, University of Oxford E-Mail to: Darryl.Stellmach@anthro.ox.ac.uk Mail to: Wolfson College, Linton Road, Oxford, OX2 6UD, United Kingdom  Author’s accepted version.  Published in Volume 38 Issue 2 (June 2014) of Culture, Medicine and Psychiatry . The  final publication is available at Springer (link.springer.com) via http://dx.doi.org/10.1007/s11013-014-9371-1   # Humanitarian action has attracted increased anthropological interest in the past decade.  Life in Crisis  is a significant addition to this literature: the first book-length ethnographic monograph of a medical humanitarian non-governmental organization. It is the product of nearly ten years’ reflection on the medical aid group Médecins Sans Frontières (Doctors Without Borders or MSF). Since 2003 Peter Redfield has spent time in MSF’s projects in Uganda and at various international offices. His work draws on these experiences, as well as in-depth reading of reports, press materials and reflections  by and about the organization. MSF defies easy definition. With five headquarters and a complex assembly of national offices and interventions MSF is a loosely coordinated—yet highly  professional—medical collective. Redfield asserts that, despite its decentralized and often disordered nature, the movement is united by its secular humanitarian belief in the sacredness of human life. Encapsulated in the assertion “‘people shouldn’t die of stupid things’” (p. 65), MSF’s self-justified mandate is to witness and act (quickly, modestly, medically, materially) to prevent human suffering. For Redfield, this “ethic of life” and call to urgent action creates a moral and political discourse wherein “action itself stands for virtue” (p. 1). Experiences of the body, illness and health are universals we all relate to; the medical act—particularly when performed in moments of extreme suffering and under the media glare—has a redemptive quality. The emancipatory promise of medical humanitarianism is one of Redfield’s core fascinations. The question of salvation   $ underpins Redfield’s analysis: who is being saved, who is doing the saving and to what ends? The first two chapters examine these foundational constituents of the MSF worldview: emergency and the ethic of life. Chapter 1 delves into concepts of crisis and emergency while Chapter 2 traces the history of how human life came to be seen as sacred. Drawing on the work of Foucault and Agamben, Redfield asserts that contemporary emergencies are characterized as a “state of exception”, that suspends social norms in favor of minimalist interpretations of life. Custom, individuality,  biography and dignity are subordinated to the bare essentials of biological survival. This transformation makes human life amenable to MSF’s medical-technocratic intervention, what Redfield calls “minimal biopolitics”. Yet, he insists, medical humanitarianism is in contrast to other technocratic interventions: it ventures to sooth individual pain, not address structures. MSF’s humanitarianism is not a recipe for individual or social welfare, but a refusal to view individual human beings as political instruments. Redfield traces this view to secular enlightenment thinkers. To the enlightenment mind, human misery could be senseless, without spiritual, moral or philosophical merit. Thus attempts to prevent suffering could be intrinsically moral, a form of secular redemption. This notion of secular sacred life would take root in European philosophical-moral tradition. The sentiment would color the creation of the Red Cross, medical missionary movements, human rights discourse and post-colonial “discovery” of the “third world”. It would also drive the Cold War-emergence of Médecins Sans Frontières as a globalized,   %  borderless, media-savvy movement that practiced a “secular faith of medical care” (p. 59). Chapter 3 examines what Redfield characterizes as “vital mobility”: the central importance of speed and self-sufficiency in the wake of emergency. Redfield traces an iconic aspect of MSF’s mobility: the “humanitarian kit,” modular, prepackaged essentials for medical care. Far more than standardized drug lists, MSF’s kits are pre-packaged infrastructure for every aspect of an aid intervention. There are cholera kits, surgical kits, camp kits, vehicle kits; a kit’s components might fit an overnight bag or fill several freight containers. Listed in a catalogue, stored in a central warehouse, a selection of kits can be dispatched globally, within a matter of hours, to fit the specifics of a given crisis. A “portable map of frontline medicine” (p. 89), Redfield links the kit with Bruno Latour’s notion of an immutable mobile, a distillation of knowledge into material objects, a universal template that permits order to be imposed over chaos. Yet standardized medicines do not make for standardized bodies or standardized interventions. In most humanitarian settings crisis is essentially open-ended—poverty is rife, threats to health and security are many—the kit might make for speed and self-sufficiency in intervention,  but cannot determine when intervention should end. In Chapter Four Redfield considers MSF’s moral stance as a witness to suffering. Medical practice gives unique insight and authority. But making public denunciations can  be politically and ethically complex. In moments when it may be risky for doctors to speak as advocates for patients, it may still be possible to make facts speak for   & themselves. In MSF, Redfield asserts, facts can speak in two ways: through voices of  patients, in the form of testimonials, or though the use of statistics and research to demonstrate to quantitative impact of health crisis. Words (people telling of experience),  pictures (making suffering visible) and numbers (to quantify and validate the extent of suffering) combine to make a powerful argument. These forms of evidence, separate and combined, “… seek to establish the facts of suffering and thereby to make a moral claim” (p. 114). The trend within MSF is to an increasingly central role for descriptive data, epidemiology and research. As the organization more frequently engages with governments, pharmaceutical corporations and the medico-scientific establishment, hard data comes to be more effective than passionate denunciation. In this way, MSF occupies the role of a “less modest witness,” an engaged but reliable party that puts forward a truthful representation of reality—direct, objective, verifiable—alongside a moral discourse on human decency. Chapters Five and Six highlight a core paradox in MSF’s action. MSF claims to value all human lives equally, yet equality cannot be borne out in practice. The ambiguity inherent in organizational roles is the subject of Chapter Five. With an intervention model of mobility and temporality, footloose singles are those most readily able to adapt to the demands of the institution. However, MSF relies primarily on staff drawn from the local  population—medics, drivers, administrators—who come with their own family ties, local loyalties and attachments. There is often acute imbalance in wealth and status between (often young, inexperienced) expats and long-term local staff. In a similar vein, Chapter Six uses the concept of triage to show how practitioners ration resources, ration care, and
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