This study is an analysis of the major stepping stones that mark the entry of medical humanitarian aid into the communication arena.Today it is clear that without the association with the world of communication, the medical aid scene would look slightly different, both from the inside and from the point of view of the public, whether they be donators or mere onlookers.We have consciously limited our scope to the field of medical aid and we focus on the actual emergence of the term “humanitarian aid” in everyday parlance.We have not set out to analyse the whole field of humanitarian aid, which would suggest that there is only one standard field on which a general analysis could be performed (e.g. Ryfman, 2004). We shall concentrate on a French case, that of Medecins sans frontières (MSF), an association that has been at the forefront of many changes which have given rise to a “humanitarian aid sector”.This case seems particularly useful in demonstrating the impact of communication on the dominant values in Western Europe.
Medical aid will be the main focus of our analysis: the evolving figure of the doctor, the emergence of a certain way of speaking stemming from the intervention of specialists in communication, the development of human values and the birth of a duty and later a right to, aid.We shall divide these topics into three sections: firstly, communication and growth, with as a common theme the birth of a new concept, that of advertising humanitarian aid; the second section focuses on growth and efficiency, with the gradual change in the founding values of medical humanitarian aid due to a wave of compassion in France following humanitarian advertising; lastly we shall look at the communication systems in more detail.
1. Communication/growth: the birth of humanitarian advertising
It is important to begin this section with a reminder that until 1976 (the date is that precise), humanitarian action was a marginal phenomenon and the term “humanitarian” was very scarcely used or recognised.Humanitarian aid became well known following MSF’s first advertising campaign, in 1976.
1.1. Before 1976
- The relay
First, let’s go back to before 1976: MSF was founded in 1971 by journalists and doctors sent by the French Red Cross to Biafra, a province of Nigeria.Initially known as GIMCU (=Groupement d’Intervention Médicale et Chirurgicale d’Urgence) and then renamed MSF, the association was very small and members were all voluntary, and all from medical or paramedical fields.The association had no financial autonomy, although independence would not have changed anything given that missions were selected and not imposed.MSF served as a relay for professional, structured organisations needing volunteers.The name “MSF” was just the name of a little association of nurses who accepted to join health missions abroad.
- Speaking out
The association was well-known in circles familiar with the doctors who had symbolically broken the Red Cross charter (based on the Hippocratic Oath) on not divulging information on what had been seen or heard during a mission.The GIMCU/MSF members used what they called “testimonies”, that’s to say speaking in public to relate what they had seen and heard during the mission.The new association was therefore founded on different values to those of the Red Cross.
- Urgency
In these conditions, the notion of urgency or emergency was quite different and indeed, rarely mentioned. During the great famine in Ethiopia in 1973, famous for bringing about the downfall of the emperor Hailé Sélassié, MSF made no attempt to alert or declare a state of emergency (via widespread messages in the media).The state of urgency of a situation only came with their financial independence, which in turn was a prerequisite for working with the new world of communication.
1.2. 1976: first advertising campaign for MSF
Social communication, known today as institutional advertising, is a concept of marketing and corporate communication.Social communication is based on the behaviour of a society’s individuals, on whom advertising evokes an emotion.It was Jean-Pierre Audour who laid the foundations in 1976.With the MSF contract a whole new sphere of communication came to the forefront.Advertising was no longer simply a question of inciting to purchase, it was a case of rousing an emotion.The cherry on the cake was the combination of a shared emotion with the idea of being public welfare.This new means of communication became known as “humanitarian advertising” following the success of MSF’s first advertising campaign.
1.2.1. Branding compassion
- The context of the take-off of advertising
In the sixties, in France, the arrival of the television in every household caused massive changes in behaviour, both individual and collective.From then on, programmes were subject to precisely calculated audience measurements.The increase in the number of channels offered a wide array of entertainment and news.Television took over from the radio as a political tool.
The impact of a programme could be measured quantitatively and so profitability rapidly became part of the audio-visual sector.The use of this new tool to sell a product (and reach the largest possible audience) as well as campaigns on the media used hitherto (posters, radio, newspapers) was a goldmine for a company’s sales team.Each part of a network, each page of a newspaper had a price. The seventies were branded the decade in which advertising really took off.Turnover reached 2 billion centimes per year. The number of televised advertisements had gone from two minutes in 1968 to eighteen minutes per day.Advertising became a tool for economic powers and fulfilled its role as a bolster to mass consumption (Vallaeys, 2004).
- Strategy
In this type of campaign, advertising professionals mainly played on compassion.
Jean-Pierre Audour, the inventor of the “social communication” concept, quickly understood that MSF could instigate a new form of communication.The rather negative “hard-sell” connotations of advertising were a factor in the MSF members’ initial reticence to Audour’s proposal. They argued that they did not want to be sold like a vulgar washing powder (Kouchner’s reaction to a proposal for an advertising campaign for MSF – Vallaeys, 2004). Before 1976, humanitarian advertising was practically inconceivable as the incitation of an emotion had only hitherto been used to sell, rather than to raise awareness.
Compassion plays on a sense of community (asking for help from the whole of humanity) and also on a sense of cosmopolitanism (we are equals, we all belong to the same world).Braudel’s analysis of “world systems” transpires neither in the Audour project, nor in the MSF project. Here, “Sans Frontière” or “without boundaries” takes on a whole new importance.…what McLuhan called the “global village”. This global-ness is possible thanks to progress in technology and an increase in the number of people with access to that technology. We prefer this term to “democratization”.
Here, we should give a few details on the way in which the sans-frontière movement was part of the intellectual environment of that time.Although the sociologist Philippe Ryfman (Les ONG, 2000; L’action humanitaire, 2004) mentions McLuhan’s impact on the founding ideals of humanitarian action, it should be noted that the movement has no real “ideological” (not in the Marxist sense) foundations.
With hindsight, it is easy to accept Ryfman’s analysis of this point: the autobiographical works of various people involved in humanitarian action (Kouchner, 1986; Brauman, 1998; Micheletti, 1999; Lebas, 2003; Rufin, 2002) show no trace of a scientific foundation. On the contrary, the movement was developed on a spur of the moment basis.
The acknowledgement of the lack of an ideological foundation should not be seen as a value judgement: we have no intention of judging an action by the depth of its foundations.However, it is important to remember that what we know now, was not evident at the time.
Let’s go back to the strategy for the first advertising campaign.Audour teamed up with Ange Casta, a journalist and documentary film-maker well-known and highly acclaimed in new television circles.The idea was to show a report during a peak hour political-cultural programme at the same time as running the campaign.The impact of the MSF advertisements aired after the report would be higher given that the audience would associate MSF action with concrete events.
In the wake of the advertising campaign backed by a report came another first for MSF, the creation of a logo and a slogan.The slogan ‘We have 2 billion people in our waiting room’ and the red band logo became a part of the MSF association.The campaign was a huge success: the association’s revenue increased 13 fold in the first year and 8 fold the following year.Thanks to this campaign and to private donations, MSF became well-known and acknowledged by the general public.
- The arrival of the term ‘humanitarian’
From then on, MSF’s work was classed as humanitarian, because, being borderless; the doctor was not at a single patient’s bedside, but at the bedside of an individual belonging to humanity.That was the message that the association wanted to get across with the reference to a global waiting room.Borderless medical care therefore became humanitarian medical care.The term ‘humanitarian’, until then used as an attributive adjective, became a noun. The new stars of the show, the doctors without borders, became humanitarians.This new use of the term became engraved in public minds thanks to the work of the journalists who reported on the new campaign.
The partnership between humanitarian action and communication professionals resulted in the two being interdependent; sales and marketing rules meant that actions were described using the adjective “good”: humanitarian action means doing good; the representatives of the ‘good-doers’ were carefully selected so that the public could clearly associate the action with the person; differences of opinion were smoothed over so as to have just one ‘voice’; images, places, conflicts were selected so as to best ‘get the message across’ and raise awareness about a cause.
1.3. The consequences of the campaign
With the mediatisation of suffering, health becomes a political issue.But before it became an issue, it went through a phase of being normalised by society.Without border-ism is not just a new area, where individuals are part of a world community, above all, it shows that health is the base of a political society: it is normal that in a ‘developed’ society individuals are cared for and where possible cured by a professionally trained doctor.Health is also the basis of a market economy.
By playing on compassion in the campaign for humanitarian action, health is therefore also presented as the corollary of happiness.The child on the poster is not smiling and does not seem happy.He is sad because he is ill, because he needs a doctor and most of the time there aren’t any.The audience therefore reasons that to help the child they need to send him a doctor who will put a smile on his face because he’ll be cured or healed.
The logic put forward by medical humanitarian action and taken up by advertising professionals is childish and its main advantage is to make those who question the logic seem heartless.It is clear that nobody would wish anyone else to suffer but it is essential to give some depth to this reasoning.
The geopolitical context has been removed from the image on purpose. This broadens the possibilities of identifying with the situation (that could be my neighbour or an African) but above all it dispenses with the need to understand that the illness is the consequence of politics.
The fact that most of the illnesses and injuries are the result of conflicts or epidemics due to war or a government paying insufficient attention to sanitary conditions is not relayed by doctors without borders.
Of course, it is difficult to explain all that in an advertisement, but the general public – and journalists – are likely to jump to false conclusions which contribute to the image of humanitarian action being an illusion.This illusion has been contested over and over again (e.g Brauman, 2005).
Aside from the health/happiness corollary, the members of the association are portrayed as heroes, an image which has received much criticism.It is no longer the victims who are on the front pages. It is the people who take part in missions, because journalists ask them to recount what they saw.
The wording of the account should be distinguished from the denunciation of the situation. The aim is to show that ‘I was there’, to show that the member was witness to events rather than trying to get the events to cease.A large part of the member’s work is set aside and the focus is on the techniques: a competent doctor spent 2 weeks in a village on the other side of the world to help the local population.
We should add that this approach has changed and today both doctor AND patient can be seen together on the same photo, in the same text.The domination of the doctor is gradually giving way to cooperation between both parties.Moreover, the doctor’s account enables potential donors to get a better idea of what is done on a daily basis: it is no longer an account given on return, it is direct reporting from the field.This makes a major difference, for communication puts a new face on humanitarian action: the face of the result of the action, which the reader can judge for himself.
2. Growth/efficiency: a reformulation of founding values
Accepting to use advertising for humanitarian action enabled MSF to increase its budget right from the first campaign.From then on, the little association had to get organised as far as accounting and communication was concerned.This requires special skills that the association’s doctors do not possess.A secretary was hired. This was a major upheaval as it brought salaried activity to a world of volunteers.Next came a person responsible for accounting and another in charge of communication.
The association began to take shape and started organising its own missions, as it now had the funds to do so.MSF was no longer a relay for other organisations and became an organisation in its own right.But the other side of this picture is that MSF began to have a responsibility towards its donors. Actions had to be justified and legitimised so that donors could continue giving and remain faithful to the association so that action could be continued.
2.1. The birth of a need for durability
An occasional donation such as one made after the 1976 campaign turned out to be problematic as it was not long term.Of course, the association was now acknowledged but it still had to prove its worth, not only in the field, but also by convincing its audience of the usefulness and efficiency of its action.
- Direct marketing
The regularity of donations as well as the viability of a field mission are part of the influence of a campaign.The more people are reached, the more impact the campaign has, in terms of money raised, number of new volunteers and media coverage.Claude Malhuret (president of MSF at the time) was well aware of that.When he returned from a trip to the USA in 1981, he brought back a new communication tool with him: direct marketing.This new tool is based on three techniques: mailing, street marketing and telemarketing.The example of the first “letter to donors” (a first in this field) is striking: the text was drafted then edited by the founders, then lists of subscribers were found (including those of a catholic magazine) and specific criteria were applied so as to select the potential donors among them.The letter to donors was 4 pages long with a photo: it tells the true story of a young Ugandan girl whom MSF were able to cure. Today, storytelling is acknowledged as a communication technique, with specific methods for the objectives requested.
Along with ‘social communication’, marketing direct became the foundation of the new ‘humanitarian economy’.
- Humanitarian aid – a great national cause
In 1986, the MSF association, a registered charity, obtained the ‘Grande cause nationale’ (major national cause) label which allowed it to obtain advantages such as free TV slots.The crossover seemed incompatible: how could an NGO acknowledged by the state pretend to be neutral in its action?At the time, this point did not seem worrying and the state backing was actually a sign of quality included in the advertising copy.
After the political element came a financial element when donations become income tax deductible.The analyst Bernard Hours (2001) saw that time as marking the birth of state humanitarian aid.As far as funds were concerned, MSF teamed up with major industrialists and accepted cobranding, that is adding the MSF logo on a major brand, so there were MSF yoghurts or shampoo.
2.2. Setting up a management team
However, all these actions actually led to the association’s first deficit in 1988.This was due to a serious lack of management know-how, amateurism and a lack of transparency when allocating missions.In 1987, a deficit was registered but was covered with the previous year’s profits.The revenue of over a hundred million francs was not enough to cover expenses and a ‘budget commission’ (Vallaeys, 2004) was therefore constituted to take charge of making savings and to test the viability of missions.This worked and the association did not remain in the red for long.
- Identity crisis and taking a stance
Testing the viability of each mission shook the foundations of MSF’s action. The question that now had to be asked each time: ‘how to promote, why and what for exactly’ revealed 2 very different visions of commitment within the association.The first way of thinking advocated long-term action, the second saw emergency aid as being more important.
These two points of view can be examined in the light of growth: the first demands continuous growth (Vallaeys, 2004) and the second does not – (“Accumulating more money won’t make us more valid”, Vallaeys, 2004).
Another way of looking at this is the geopolitical implication: the first group would set up durably in the country, even if that meant doing the health ministry’s work for it; the second group would say that that is contrary to the foundations of humanitarian aid. It does not mean acting on public health, rather a doctor’s action should involve caring for his patient without looking to what may have made him ill.
The second argument won: missions were short term and as politically independent as possible (which was later to be the essential distinction between those encouraging the right to interfere, when the second group restrained themselves to the duty to interfere)
- Crisis management and efficiency: the example of Kurdistan, 1991
Following the 1st Gulf war led by Bush senior, there was a mass exodus of Kurds on the Turkish borders.On the spot, 2 MSF members followed the human tide: one of them got hold of a video recorder and filmed a few sequences to have some proof and be able to talk about a situation not yet covered by the media.
When Dr.Marcel Roux, one of the two members returned to France, a press conference was called in which he used the term genocide, despite the instructions he had been given when the conference was prepared.The conference was covered by the international press and led to the UN Security Council voting a new resolution (n°688) which condemned the mass repression of civilians and to the ‘humanitarian phase’ of Bush senior’s war and the ‘provide comfort’ operation.
The press conference organised by MSF on Dr. Roux’s return attracted a vast number of journalists to that part of the world and put pressure on the political agenda. This underlined the growing impact of humanitarians and showed that their accounts were taken into consideration.
As far as managing the crisis is concerned, MSF can be proud of having been the only organisation on the spot (along with the Turkish Red Cross). This improved its reputation in terms of recognition and competence but also prepared the ground for the conceptualisation of the action that was later classed as interfering.Yet MSF members insisted that the work should not have been done by them because the exodus could have been avoided if decisions had been taken well in advance by governments. Humanitarian action as a political resource is not how they see their role (Vallaeys, 2004).
The politicization of humanitarian action, dependence on mediatisation and organisations being in the hands of their financial backers are the bane of MSF’s life.This is due to the bureaucratic institutionalisation, to the management system that is beginning to resemble that of a company.So what is the difference between a doctors without borders not- for-profit association and a company ?
Communication system
3.1. The means of communication
These are identical to those of a company.These means of communication require qualified, specialised personnel. The communication department has to remain independent in order to prevent campaigns being taken over by a holding with specific interests in certain countries or special relations with certain governments, which could influence the presentation of the situation or the choice of message. MSF has managed to safeguard this autonomy since 2003 and campaigns are no longer drawn up by external agencies but by MSF’s own communication department.
In concrete terms, the means are the following:
-Posters, film advertisements
-press relations
-events
-the website
-external publications (the association’s reviews, scientific publications)
-Direct marketing: mailing (electronic or paper newsletter), street marketing, telemarketing
-social networks:Facebook page, for example
-banner advertising on other websites
We think that the arrival of web 2.0 has changed the humanitarian approach of members engaged in action.Information circulates more rapidly and emanates from varying sources.It is easier to obtain information on a precise situation (e.g. tweets from the Libyan rebels) but evidently this sort of information must be treated with caution, as should all information given by MSF.
Information is easy to cross-check and knowledge is widely available, but this should not hide the fact that even if potential donors can easily locate Misratah and find out the exact cause of the revolt, they still play a passive role in the conflict as spectators of the suffering and strife of others.A spectator may be in front of a television, a radio or a computer.
3.2. Objectives of communication
For companies and large associations alike there are two main avenues, brand communication and professionalism.For associations, there is also the dimension of awareness about a cause, necessary to incite reactions and disseminate information.These two avenues facilitate the act of donating.
We underline the fact that the use of a communication department followed a period in which media appearances were made due to a need to recount events seen on the spot involving regimes unknown to the general public, but media coverage also made up for the fact that the association could not pay for a poster campaign.
Before 1976, MSF could not convey messages to the general public, or only occasionally, when waxing lyrical in an article or report, for the association was dependent on the media: if MSF doctors were not invited to give interviews during the TV news bulletin or on major radio programmes, they had to take to writing articles for newspapers in order to get their messages across.The association managed to overcome this dependence by becoming financially independent.
The, initially free, collaboration from advertising agencies enabled the association to collect funds and gain international influence by demonstrating its skills (organisation – creation of a logistics department, structuring – kits for the various types of mission, creation of emergency hand books which were later taken up by all large organisations).
This financial independence was gained at the expense of voluntary work, as it implied corporate-type organisation and management.
3.3. Clear communication, with defined borders
The last point that will shall examine is the relationship between the message to be conveyed, and the person who conveys it.In other words, how the message reflects upon its author.It is interesting to note that while MSF is an international organisation, with operational sections throughout the world, each with several offices (for recruitment and fund raising), it manages to communicate with a single voice.Do communication and polyphony go hand in hand?
If each section is to be independent, then yes.At first, that may seem strange for an association based on having no borders.
- A need for international unification
Differing points of view expressed by doctors from culturally and geographically different sections became particularly evident following the crisis in Somalia (where MSF Belgium took a different stance to MSF France) and also following the crisis in Rwanda.Between 1996 and 1998 a need for international unification became apparent and was clearly expressed by MSF Switzerland (Vallaeys, 2004): financial resources are no longer sufficient, it is illusory to believe that funding is independent; governments set down conditions on obtaining funds.
Cooperation between sections works well, as the example in Kurdistan in 1991 showed.However, that is true for one-off missions, not in the long term.The reality is that there is competition between sections, a puerile race to be first past the post (Vallaeys, 2004).
The creation of an international council in 1989 changed nothing.Fundamental disagreements rose to the surface and in 1998, the newly elected president of MSF France stressed that each international section would be autonomous again.The outgoing chairman of MSF France, Philippe Biberson stated: “I believed in the wealth of expressing different points of view, I expected constructive dialogue between the different cultures and nations rather than systematic competition”.
Instead, he observed “quarrels about structures, over who was the superior power, who would speak to the international media on behalf of the whole association”(Vallaeys, 2004). People without borders, united behind a logo, all with the same role, but with different ideas about what their commitment entailed.
It is quite natural for there to be differences of opinion within a community. That was one of MSF’s strengths at the outset.But once a professional communication system is in place, having people singing from several hymn sheets prevents or hampers action.Having different “voices” makes understanding the action problematic, not understanding the reason for it, but the reasoning behind it. A group of people supposedly share the same ideas, but do not make one clear statement.
One of the positive aspects resulting from the collaboration between humanitarians and institutional communication is the clarification of the guidelines for taking action which were as blurred as the code of ethics.In the end, the deciding factor is the commitment of individuals as individuals rather than as doctors.MSF doctors bear the MSF stamp, but they carry out their missions as men and women, as citizens of the world.
At the beginning of the new millennium, the field of humanitarian aid became an economy with calls for tenders, an exponential increase in the number of NGOs (with, the advent of MONGOs, My Own NGO), humanitarian aid taking up a larger and larger share of the budgets of sovereign states and supranational institutions.All this led to States offloading social responsibilities (health, security, education among others) onto the private sector, which had obvious juicy repercussions as new markets opened up in the tertiary sector.
Humanitarian agencies become subcontractors (Vallaeys, 2004), operational agents for institutions and the concept of NGO loses its N.Nobody is naive enough to think that an NGO would survive without backing from the OCHA or the EU, who are among the major financial backers on the international scene. We should add here that although the above are the biggest backers, there is a strong tendency, especially in industrialised countries to forget the importance of the role played by Middle Eastern and emerging countries in financing humanitarian aid[1].Money has a smell, say the staunch defenders of the “N”. That’s all well and good, but still, nothing much gets done without it as Rony Brauman, ex-chairman of MSF, might say.It is precisely this point that destabilised the organisation. From 1981 onwards, MSF decided to employ a communication technique from the USA: direct marketing.It became one of the cornerstones of the organisation and paved the way for other new techniques.From then on, the communication/economic growth tandem was at the helm.
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[1] See study : ROBYNS, Alain et de GEOFFROY, Véronique : Les pays émergents comme bailleurs de fonds de l’action humanitaire. Le cas des pays du Golfe. Réalisé par le groupe Urgence-Réhabilitation-Développement (URD) du Centre de Crise du Ministère des Affaires étrangères français. Novembre 2009.
Stéphanie Herber
Stéphanie est Doctorante à l’Université de St.Gallen, Suisse, son sujet de recherche se concentre sur l’aide médicale d’urgence internationale.
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