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This chapter analyzes the role of charismatic and expert voice in articulating the message of human rights campaigns. Both collective and individual voice are considered. The chapter profiles the heroic presence of Nelson Mandela, Aung San Suu Kyi, and Argentina's Mothers of the Disappeared. It discusses Doctors Without Borders, Amartya Sen, and Paul Farmer as witnesses and experts. These leaders are contrasted with insufficient use of voice in American campaigns against the death penalty.

Despite the government's intransigence regarding antiretroviral treatment, islands of access to such care began to materialize in the late 1990s. Clinical investigators capitalized on the interests of pharmaceutical firms in conducting research in South Africa. Appalled international humanitarian relief organizations, including Doctors Without Borders, sought to underwrite limited treatment efforts. And within the corporate sector, some of South Africa's largest firms extended medical coverage to include antiretroviral therapy, either through health insurance or directly through company clinics. Those who pressed for such innovations believed that by demonstrating the efficacy of treatment, they would not only meet the clinical needs of patients, but provide a powerful antidote to the stigmatization attached to HIV infection and a moral challenge to President Mbeki and his administration. They were aided in their efforts by an innovative and effective grassroots organization of HIV positive people and their supporters, the Treatment Action Campaign.

In 2014, the world began to witness an unprecedented Ebola epidemic in West Africa that is now smoldering. Ebola had a fatality rate of 40% to 60% in this epidemic due to a lack of adequate health infrastructure and overwhelmed aid organizations at the height of the outbreak. These grim prospects quickly prompted proposals to use experimental treatments and vaccines for Ebola that were in the earliest phases of development at the time. Doctors Without Borders/Médecins sans Frontières (MSF) played a key role in the rapid launch of clinical trials of the available experimental interventions. This chapter traces how MSF negotiated the trials under challenging circumstances, focusing on trials of experimental treatments. It provides a detailed account of the difficult tradeoffs MSF faced and shows how the organization’s values and beliefs shaped key decisions about research priority setting and clinical trial design.

The contemporary security environment presents a challenge for Doctors Without Borders/Médecins sans Frontières (MSF). It exacerbates a tension that has shaped this organization since its inception, between its role as a humanitarian action and emergency response organization and its advocacy for global health justice. The 2014-15 Ebola outbreak in West Africa underscored this tension. This security landscape also offers an opportunity to move forward. The chapter argues that MSF should embrace its security actorness without reservations, embedding its emergency response role within a conception of health security that looks toward the alleviation of harm and vulnerability. MSF can also move forward by acknowledging the broad transformative potentialities of health interventions. MSF should revisit its approach to borderlessness in a global health arena that is still strongly determined by multiple borders, not just territorial divisions but also inequalities based on gender, race, class, and sexual orientation.

In chapter 2, Heather Pagano and Marc Poncin detail, from the perspective of Doctors Without Borders (Médecins Sans Frontières), the unique features of the outbreak that made past approaches to filovirus-infection emergencies inadequate, as well as the core reasons the global response preliminarily failed. The chapter describes how the dispersal of small numbers of cases over a wide geographical area multiplied the human resources, logistics, and laboratory capacity required in each individual location to bring the epidemic under control while also presenting communication and coordination difficulties between MSF, healthcare workers, UNICEF, WHO, and the US CDC. It analyzes WHO leadership, including poor logistical presence and politicized decision-making. The chapter highlights the critical gaps in the formal national and international system for responding to serious infectious disease threats and the process by which those gaps may be filled by nongovernmental organizations.

In early September 2014, Doctors Without Borders/Medecins Sans Frontieres (MSF) urged governments to send military personnel and assets to respond to the Ebola crisis in West Africa. MSF emphasized that the military’s medical assets could be effectively separated from the military’s association with force and coercion to improve the quality and extent of care. However, foreign troops’ zero-casualty approach, in which little clinical care was provided, and domestic military–civilian conflicts, which arose during military-led containment efforts, suggested otherwise. Drawing on a review of images, key program documents, and news accounts, this chapter addresses the stakes and pitfalls of trying to separate military logics from military logistics. It focuses on what happened as foreign militaries largely organized their work around logics that prioritized the “rescue” of foreigners and risk avoidance, and as domestic militaries, at least nominally, secured state interests by threatening violence against vulnerable citizens.

When several small disasters occurred in rapid succession during the larger unfolding disaster of the Ebola epidemic in Liberia, the fight against Ebola seemed increasingly hopeless. This vignette recounts just such a moment. In late July 2014, Doctors Without Borders/Médecins sans Frontières (MSF) staff had to decide whether to remain on the ground after Samaritan’s Purse, the only other international nongovernmental organization working with them in providing care for Ebola patients, withdrew from the country after a healthcare worker became infected. At the same moment, violence against healthcare workers in the Ebola response was rising, as was the number of dying and dead. Ultimately, the choice to stay in the face of an impending human catastrophe did not derive from organizational logic or medical planning, but was based on a spur-of-the-moment choice driven by a sense of solidarity and commitment.

On July 29, 2014, Dr. Sheik Humarr Khan, Sierra Leone’s leading expert on viral hemorrhagic fevers, died of Ebola virus disease in the Ebola treatment center in Kailahun run by Doctors Without Borders/Médecins sans Frontières (MSF). From the day he learned he had tested positive for Ebola until the day he died, Dr. Khan became the focal point of urgent discussion and debate on medical ethics. These discussions included the proper use of experimental therapeutic agents during an unprecedented epidemic and policies and preparedness for international medical evacuation. Healthcare workers debated ethical points such as whether they should prioritize the greater common good over the interests of an individual. They agonized over whether they could justify placing the value of the life of one person above that of another.

Doctors Without Borders/Médecins sans Frontières (MSF)’s prior engagements with the Ebola epidemic elsewhere in West Africa prevented it from mounting a robust response to the outbreak in Monrovia, Liberia, in July and August 2014. Unfortunately, this would be the time and place where the West African outbreak would undergo its most dramatic explosive growth. Faced with great suffering and mounting need for care, the MSF team in Monrovia decided to open an Ebola treatment unit, ELWA 3, despite their being woefully understaffed. This forced the team to make difficult compromises in the care it provided. These tradeoffs became the source of much controversy and debates over medical ethics and healthcare rationing, both within MSF and in the public sphere.

This chapter reviews the medical evacuation policies of Doctors Without Borders/Médecins sans Frontières (MSF) and how they were adapted to the West African Ebola epidemic. Medical evacuations for international staff were just one of the challenges facing aid agencies, but it was a challenge that weighed heavily on the response. Unable to guarantee the evacuation of sick staff members, recruitment difficulties for an already unprecedented epidemic response could only worsen. International medical evacuations are expensive regardless of the circumstances. In the context of Ebola, further complications included the availability of pilots and crews prepared to transport potential cases, along with ensuring appropriate hospital care on arrival. However, the most significant obstacle to a shared air service of pooled resources was not cash or technical difficulties but the lack of political, which became indicative of a broader fear that further isolated the stricken countries.