21/12/2011 05:03 GMT | Updated 19/02/2012 05:12 GMT

Coming of Age: Rebel Humanitarianism Turns 40

The extraordinary levels of energy that we need to do our work is the stuff of youth. And even at 40, we still have enough of the conceited, angry teenager to protest the senselessness of a rich world where so many people suffer and die for lack of medical care.

Médecins sans Frontières MSF (Doctors without Borders) turns 40 today. Creaking knees and self-reflection don't always go hand-in-hand with the can-do idealism and breakneck pace that epitomise emergency response. As I've been doing for the last few years, MSF now pauses in front of the mirror, looking for proof that it is still young.

The extraordinary levels of energy that we need to do our work is the stuff of youth. And even at 40, we still have enough of the conceited, angry teenager to protest the senselessness of a rich world where so many people suffer and die for lack of medical care. As an organisation with an annual global expenditure closing in on a billion dollars, that holds thousands of meetings and consumes several zillion cups of coffee a year, it is hard to deny our expanding waistline.

MSF's founding doctors exited the Biafran crisis in Nigeria with the unprecedented idea to bring medical aid to those in crisis even if the powers that be did not like it. Witness the birth of rebel humanitarianism.

Those first missions now seem so unfettered: arriving in a camp of Pol Pot's victims at the Thai border with nothing but three suitcases of medical supplies and a load of goodwill, or the journey into Soviet-bombarded Afghanistan on the back of a donkey and no satellite phone, now surely a violation of every security protocol MSF has carefully drafted.

Now we have guidelines to follow, databases to keep up and reports to file. Those pioneers would have scoffed at this bureaucracy. And we scoff too. The aid sector demands a bureaucracy that sometimes feels overwhelming. All the more so for an organisation led by former field workers haunted by the human catastrophes of Rwanda in the 90s, Darfur in the last decade or Somalia today, not professional managers driven by fundraising targets. But those golden days weren't so golden: back then MSF treated a few thousand per year, while in 2010 we were able to perform more than 7 million consultations.

So that bulge around our collective middle isn't simply the administration of the aid machine. It includes teams of specialised medical and logistics professionals who ensure that we are able to address complicated illnesses like AIDS or drug-resistant tuberculosis, even in a makeshift camp of refugees. At headquarters we now have scores of techies developing, for example, our capacity in telemedicine, whereby doctors scattered about the frontline can be joined in their consultations by an expert sitting in Nairobi. You could call it our 'pooch' - I prefer to see it as progress. But in the end it comes from the commitment to our patients, because our doctors reject the view that it is good enough just to treat diarrhoea and malaria. There's that teenager, pushing us to do more.

As we turn 40, I am heartened with signs that MSF retains its rebelliousness. MSF has been a constant and perhaps even shrill defender of what the international community refers to as the humanitarian space. When 'mission accomplished' in war requires winning of the hearts and minds of the local people; when helping those who are suffering is not an end in itself but is, as the British government has so publicly declared, a means to secure political interests, then MSF's staff in the field find themselves working in the crosshairs of insecurity because armed opposition groups no longer trust in the benign motivations of aid.

It is now, in middle age, that we acquire the maturity to accept what has always been true: it is ridiculous to expect governments, rebel groups, insurgents, criminal syndicates or national armies to adopt the benevolent positioning of a charitable organisation, and that the abuse of humanitarian aid is an enduring and inevitable component of the landscape in which we operate. Of course, we maintain our independence, ensuring that we are not locally perceived as part of the international - read: Western, liberal, neo-colonial, self-righteous - armada. But we are old enough to know that in the twisted world of conflict we must sometimes make compromises in pursuit of the humanitarian principles we hold dear.

We may not be able to touch our toes, but we've become more flexible. To reach people in crisis implies a price, paid to those in power without whose consent it is impossible to work. It has meant turning a blind eye to a massacre in one country or playing along with the deliberate obstruction of aid in another. There are many more examples. To reach people in crisis, then, is to know our place in the world.

To mark our birthday, we have published a book Humanitarian Negotiations Revealed in which we turn our critical gaze inward - on the successes, failures, infighting and accords that have shaped our work in the last few years. It was the equivalent of publishing our personal memoirs, even if we aren't yet old enough for that. The conclusion? With this birthday, I think, we are finally able to be honest with ourselves. That anguish, uncertainty and compromise must accompany youthful vigour and idealism if we are to save lives and alleviate suffering in the heart of crisis.