Ebola: Three Ideas (continued)

Ebola 3. A Time To Point Fingers? Yes.

We can’t dawdle on this one”. That is Barack Obama on September 16, inaugurating a litany of Very Important People sounding clarion calls that the world must act to curtail the scourge of Ebola. David Cameron followed suit. Ban Ki Moon jumped up and down, calling for urgent action, also for nations to give lots of money to the UN and for Bono to organize some sort of Live Aid rerun. To date, the action of calling has greatly dwarfed the action of acting.

There is an undeniable truth to the urgent call for action. But having dawdled for so long – allowing this outbreak to infect and kill so many more people than should have been the case – there is a fundamental deceit in the call as well. In terms of preempting the exponential spread of this disease, the time to act passed four, five, maybe six months ago. Now we must talk of action – action on the ground in West Africa (not to be confused with airport screenings, conferences full of petits fours or throwing money at the problem) – and we must talk of accountability for its opposite.

Ellen Sirleaf Johnson in her recent letter to the world: It is time to stop talking and “send a message that we will not leave millions of West Africans to fend for themselves.” With all due respect, Madam President, that ship sailed. The nations of the world long ago decided that they would do exactly that. They decided to act only when it became a matter of self interest. And I note here that this self interest seems largely electoral, a question of curtailing political damage at home rather than a virus overseas.

Rather than save lives, the response of nations like the US or UK seems designed to save political ass. Through months of inaction, these governments are contributors to Ebola’s explosive spread. And yet they are the best the world has to offer right in terms of response.  We need their boots on ground.  The lone exception to self-interest seems to be Cuba, neither threatened by Ebola nor under pressure to respond, who has pledged hundreds of additional medical doctors on the ground.

Let me be very clear: the urgency of accountability exists because at the nation-state level this is not primarily a question of charity or even humanitarianism. This is not a question of choice or option. This is a question of human rights. This is a question of nations violating their obligation to provide international cooperation and assistance to Liberia, Sierra Leone and Guinea. See for example Physicians for Human Rights or Amnesty International. (Whose voices remain curiously muted. Where is a more strident defense of the human right to health? Where are creative R2P-inspired arguments that there is an international responsibility to protect citizens against a massive violation of their human rights when, as in West Africa, the states themselves are unable to do so?).

And then this is also a question of international security in the form of global outbreak response, which has been entrusted to the most powerful nations on Earth and the UN, who had the money, know-how and responsibility to act much earlier. Finally, there is the question of humanity. These nations, in pursuit of national interest and in a rather self-congratulatory fashion, do such a good job of talking the humanitarian talk; of talking the talk of caring and aiding and helping. But when it came to Ebola, they decided against doing the walk.

Another reason to act right now on accountability is to stop its perversion. We are in danger of accepting a simple story that the World Health Organization is to blame. Well, that is true. But there is a difference between blame for WHO shortcomings and exploiting the WHO as a scapegoat. For starters, there is the impact of WHO funding cuts by governments like Obama’s USA. Or even better, as Dr. Anne Sparrow writes in The Nation, world powers have ensured that the WHO has shifted emphasis to the diseases of the Western World. But more importantly, the WHO was only one of he firemen who sat and watched while this flame spread to a fire and then a blaze and then an outright conflagration.

Will heads roll in the governments of Guinea, Liberia and Sierra Leone? It is a simply wrong to believe that the “basketcase” state of their health systems were either natural or inevitable, like a typhoon. They should have been in a better position to deal with this outbreak. It is true that the scale of the outbreak today, or even back in July, would have swamped all but a well-developed nation. But we must assess matters earlier in time, when the basics of good case management and information flow could have prevented the outbreak from escaping control. What shocked me the most is that so many of their own citizens so distrusted these governments that Ebola was first seen as a ploy to attract and embezzle aid. The abundant health education message of EBOLA IS REAL makes me want to cry. How to stop an outbreak if that is where you begin?

And yet I heard Sirleaf Johnson blame the miserable state of her country’s healthcare system on a war that ended eleven years ago. Perhaps I missed her explanation of what happened to the considerable aid sent to Liberia to rebuild. Ditto for Sierra Leone or Guinea. As Human Rights Watch notes: Endemic corruption, including in health services, has long plagued the governments of all three countries and contributed to years of unrest and lack of development. It is in the first instance not the rich governments of the world who decided to leave millions of West Africans without adequate healthcare or basic outbreak response.

Governmental failure is a matter foremost for civil society. West African voices can already be heard. See, for example, this blog post, questioning poverty in the face of mineral riches and offering judgment on governance: It is not good enough for the Deputy Minister of Foreign Affairs of Sierra Leone Ebun Strasser – King to note that Ebola “took us by surprise and met us when we were ill prepared for it”. Or Abdul Tejan-Cole, speaking eloquently on seeing “civil society step up when government institutions have crumbled or not addressed the crisis”, not because of poverty but because of poor management.

Beyond governments, will heads roll in any aid NGO or agency aside from (presumably) WHO? What of those agencies who have spent years claiming to develop health capacity in West Africa? What of those who have raised money by declaring themselves leaders in global humanitarian emergency health? Where are their beds and nurses and doctors? And where were they when the epidemic could have been controlled? The WHO was silent and even downplayed the gravity of the situation. Did they own the only working phone in West Africa? Aside from MSF, where were the alarm bells from other agencies with health teams already on the ground? Are board members going to resign in disgust? Or is everybody too busy ramping up activities to respond to Ebola the cash cow in addition to Ebola the virus?

There are those who argue that now is the time for action, not recrimination. That is the pragmatic voice of the aid establishment. And that is sweet music for those responsible, who do not in any way fear the hand wringing and promises to do better in the future which have long served to excuse failure and defuse calls for change. To delay accountability now is to reinforce this entrenched pattern of inertia tomorrow.

As did the global political elite know and ignore brewing famine in south central Somalia a few years ago, as did they know and ignore the mounting crisis in Syria, so did they know and ignore the burgeoning Ebola crisis in Guinea, Liberia and Sierra Leone. This is the new world order, in which the most powerful are either unwilling to meet their international obligations, or incapable of doing what is right and what is human until direct self-interest and fear muster the political capacity to act.

Ebola: Three Ideas (continued)

[Originally posted October 2 and lost due to website issues. Apologies to those whose comments have been lost as well.]

Part 2. Ill-suited for outbreak response

And now, for something completely unoriginal: fear of Ebola is doing as much damage as the virus, maybe more. Yes, you knew that. Many have called fear a primary driver, a vector not just of the epidemic but of “collateral” deaths as well. Vox populi across Guinea, Sierra Leone and Liberia confirm a frightening view of humanitarian aid – hospitals are seen as a mixture of deathtrap and house of horrors, the people trained to treat the disease as transmitters or killers. As Jeffrey Stern concludes in his excellent Vanity Fair article, the outbreak would have been contained early on, but people took Ebola underground due to fear and distrust; it later emerged a multi-headed Hydra.

I remember similar issues arising in 2005, when a major outbreak of Marburg haemorrhagic fever had Angolans in the town of Uige running away from – you guessed it – space-suited health workers and afraid to enter hospitals. There too, insensitive burial of the dead sparked anger (so MSF began involving family members in a safe way, allowing them to see the corpses of their loved ones for themselves, stifling wild rumors).

Fast forward to frequent stories of healthcare teams being attacked (e.g., eight Guinea village health workers hacked to death only last week, month nine of the outbreak) that signal an almost primordial reaction. And there should be no comfort in believing such fear only happens in oogabooga land; that these West Africans are depraved, brutal, and primitive. Spielberg, no stranger to scaring us, had space-suited agents invade Elliot’s house to capture ET. Why? Because they breathe like Darth Vader, walk like Frankenstein, and frighten the bejesus out of us (check out the clip). Recall also the hysteria and even violence surrounding HIV/AIDS in the US. Or current scares for Ebola zombies. Or the fact that the discovery of one Ebola patient in the USA wiped billions of $$$ off the value of airline and travel stocks.

From an intellectual perspective, the nature of Ebola has a lot to do with the fear. It’s an exceptional combination of fatal and gruesome. More viscerally, though, the terror of Ebola is epitomized by the protection-suited doctor or nurse. Part hazmat worker, part astronaut, part faceless invader. They walk like robots. Part alien, part monster, part inhuman.

aliens

Thus far, the suits seem an unavoidable measure to protect healthcare workers, although some claim such measures are both costly and counterproductive (see here or here). Even if proven that the suits are necessary, we must recognize and combat their perverse impact in driving epidemically dangerous behavior. Hiding from assistance, spreading the disease to family, neighbors. Or maybe the family throws stones to chase away health workers. A fear so strong it permits murder.

But if the suits are necessary, and if they engender such fear, the next question is one I do not see debated: Should treatment and the use of protective suits have commenced so swiftly? Does rapid mobilization cost more lives than it saves in certain outbreak situations? Are there times when the outbreak response – almost universally a model calling for speed in gearing up treatment/vaccination– needs to slow down, at least in terms of the HazMat invasion, to allow populations to be prepared?

Stern: The foreigners [treatment and sensitization teams] had come so fast that they had actually out-run their own messaging. After the Marburg outbreak in Angola, there was even talk of getting the outreach workers and psycho-social experts onto the ground in the first plane, in addition to prioritizing the deployment of infectious disease specialists (see here for old but insightful MSF lessons learned).

Beyond big picture questions, what about the small-focus, right at the point where doctor meets patient? Or, more accurately, where they don’t meet. Those protective suits do more than spread fear and distrust. They are transformational, diminishing treatment to its therapeutic minimum, leaving doctors dehumanized and detached from the people they are attempting to heal.

Here’s MSF’s Dr. Gabriel Fitzpatrick on not being able to comfort a sick, solitary child: The child was clinging on to the nurse, searching and hoping for comfort in a place which does not allow direct skin-to-skin contact. As a father myself, this image stuck in my mind. Heart wrenching. Here’s Dr. Douglas Lyon: In my spacesuit, I won’t be able to connect and provide reassurance with a smile, body language or a concerned look.

On the flip side, patients remain gravely ill, isolated and terrified. Imagine not knowing what your doctor or nurse looks like. There is a need to insert some human into humanitarian, to enhance the human touch. Design changes in treatment centres are a good step, like using a double line of fences to create a safe distance for viewing and talking. Here’s an idea from Dr. Leslie Snider: How about a book or a doll to show children (adults too!) the person underneath a HazMat suit?

Here’s another idea: What if somebody made transparent protection suits? Until that time, though, what about attaching a big photo of the doctor or nurse to the front of the suit? In other words, pasting a smiling human over the alien invader; allowing the Ebola patient to look his or her doctor in the face.Put a name on it (Dr. Marc!). (How about a flip book with several photos in it? – reassuring, sympathetic, happy, sad, sweaty mess, hugging a cured patient...). One small step towards treatment based on a more human doctor to patient contact. One medium step away from zombie therapeutics.

Ebola: Three Ideas You (hopefully) Haven’t Read

[Originally posted September 26 and lost due to website issues. Apologies to those whose comments have been lost as well.]

Part 1. The Ebola crisis is in part the self-fulfilling prophesy of the way we think about Africa.

The Ebola crisis in Liberia, Sierra Leone and Guinea consumes no shortage of attention in mainstream Western media. Other African crises like CAR, Libya or Sudan, let alone success stories, should be so lucky. Then again, maybe attention isn’t such a good thing after all. Some of it quite responsible, much of it still trades in outworn stereotypes of a continent awash in warlords, loin cloths and killer microbes.

Hooray for resistance to sloppy Ebola storytelling, for example Dionne and Seay’s nailing Newsweek‘s sensationalist cover story. Or earlier this week Sierra Leonean Ishmael Beah skewering the way lopsided Ebola reporting reinforces the role of Africa as a foil, as a continent whose dismal failure reaffirms our superior Western civilization.

But why dump all the blame on the media? NGOs and the UN – the foreign aid establishment – surely merit some credit for perpetuating the popular notion that Africa is a cauldron of tribal brutality, a crucible of scary diseases and a reservoir of primitivism, all rolled into one waiting-for-a-savior basket. (Not to mention the rather stock idea that Africa is a country. On that geographical malapropism, see this great blog.). The point is firstly one of principle: NGOs should be truthful in their communications. Easier said than done. They appear locked into an audience (the home society public) that demands such a stereotype in order to feel compelled to donate (see e.g., my previous blog on this).

We’ve heard criticism of this stereotyping before, often from within the aid and Western media communities. Is there hope? Importantly, Beah published in the Washington Post, bringing his views to Western eyes. If only for a moment, his piece shakes our monopoly over the narrative. As I’ve written before, these stereotypes will come under increasing pressure as internet media expand access to Western debate and discussion. The question: Is the aid industry simply (!) a promoter of the distortion, or an addict as well? But that is for another blog.

The main point here is that the degree to which the monotonous, stereotyped portrayal of Africa gives rise to the conditions in which Ebola outbreaks occur. Persistent underdevelopment, bureaucratic inertia, low foreign investment, unresponsive government, the cycle of waiting for crisis rather than building systems, dependence on the foreign aid community, etc. These ills are all either caused and/or reinforced by the inaccurate portrait of a continent, in this latest episode with a virus as the star in a long line of unabated indigenous catastrophes. NGO action may be vital in combating Ebola, but aid agencies themselves helped weave the very “basketcase” to which they would nowadays respond.

World Update: It’s Big and Small

[Originally posted September 12 and lost due to website issues. Apologies to those whose comments have been lost as well.]

Monday marked six months since I stopped working in the humanitarian field – I left the insulation and employ of MSF and headed off to parts unknown. Actually, I headed off to parts known, the USA, and spent most of the half year with my wife, immersed in the day to day. Road trip. Chilling out. Taking a break. I recommend it.

We passed through spectacular natural scenery, ate sublime meals at diners whose steady disappearance is as tragic as DRC, and interrupted my 15 years living abroad to spend a full month with my aging parents. Even without its day to day excitement, the trip would have been wonderful simply for the fact of spending so many months off the grid. The phone didn’t ring. The email didn’t stack up. Stress seeped into the ether and sleep came in deep doses.

Did I find myself? Discover the meaning of life? Nope and nope. I did manage to attain nirvana in the tiny town of Webb, Mississippi. This perfection came in the unlikely form of neckbone stew at Vera’s café, with sides of cornbread, mac & cheese, and okra. That’s it? The secret of life is high-cholesterol Southern cooking? It may well be. Beyond that, this is the most I can say. First, the world is a really big place. Second, the world is a really small place.

The world got bigger the moment I left MSF. The adrenaline rush of emergency aid causes a narrowing of vision. Aid agencies churn limited ground. Outside, the world is full of joys and marvels and realities like the miserable, inexplicable poverty of many Native American communities. Or take Syria. At the time of my departure it was a daily point of focus. During my first few months in the States I never once heard somebody mention it in conversation.

The fact of the world seeming suddenly so much larger says something about the worlds in which we live. The world became quite small as well, at one point not much larger than our campervan. That is partly a function of snugness, the age old feeling of comfort or refuge in our own world. In one way, I had replaced MSF’s porthole with another, but at least stress did not fix my gaze. It felt easy at first to join the big world again.

But beyond my road-tripping, the smallness of the world is partly a new phenomenon, as internet information and social networking shrink rather than expand our understanding of issues, and solidify polarized points of view. See this fascinating piece on data visualization of Twitter action during the Israeli-Palestinian conflict: “We’re most likely to only talk to people like us”.

Since coming back on the grid, the news portrays a world in even worse shape than only a short time before. 2013 was bad enough (see my New Year’s Day send off in Huffington Post). Now add Putin’s Ukraine invasion, Ebola, the atrocities of the Islamic State, Israel’s recent attempt to rubble-ize Gaza, Libyan strife, etc.

The twinned trends of a world getting larger and a world getting smaller are not unrelated to this horrific state of affairs. For example, the more misery that piles up in the world, the more (for example) Sudan, CAR and Haiti gather into a white noise of faceless crisis, meaning these specific realities are rendered invisible from our small worlds. Or this phenomenon: in the face of all that bigness – in the face of seemingly inexorable economic and cultural massification on a global scale — there is a retreat into the local. Self-determination at the atomic level, whether it be the selfie, the slow food movement, or Scottish desire for independence. The discourse of nationalism is on the rise. That can be a good thing – ethnic pride. And that can be the success of the Islamic State or Boko Haram.

This self-determination is not only a longing for freedom or power. It is not only political in nature. It is also the self-determination of right and wrong itself. Reversing 500 years of trending enlightenment, “truth” in the form of political conviction is becoming more localized; naked self-interest more shielded as opposing views no longer enter the fortresses of small world opinion. The internet promised the globe and has in many ways delivered the (isolated) village. Safe in those narrow confines, POW slaughter is justified by religious edict and drone assassinations by self-defense.

Contrary to my hopes, 2014 suggests that 2013 was no aberration (again, see link). Of specific concern to humanitarians should be international law, human rights, and humanitarian action. These have all formed part of the world getting bigger – a concerted effort to globalize respect for certain norms and standards. Now, their meaning and hence their potency has been drained by the steady erosive forces of self-interest, exceptionalism, and realpolitik of the flag bearers.

In the aforementioned Huffington Post piece I wrote there were a “mounting number of places that have reached a critical mass of disrespect for international law and universal ideals, or their outright rejection; and where rudimentary compliance is no longer deemed useful.” My primary concern is not the upsurge of bad actors – there will always be bad actors – it’s the very public destruction of these laws and standards by the good actors, or at least of those who typically advertise themselves as good. In the long game of establishing rules against summary executions or slavery, the act of a jihadi beheading a journalist is a call for strengthening international law; the act of the US government torturing prisoners in Abu Ghraib is a knee-capping of it. What is good for the goose is good (easily justified by) for the gander.

(Diversion alert) The US government should take a lesson from Charles Barkley, who understood there are insidious consequences when the public anchors their beliefs and aspirations in the wrong place (see clip): “I am not a role model”. Sadly, such public self-awareness is not the stuff of nations. Here is Samantha Power a few days ago, banging the drum of international order against Mr. Putin’s Ukraine transgressions: “These rules and principles that have taken generations to build, with unparalleled investment – countless lives have been lost to establish and defend these principles.” Ouch. There falls another brick in the house of international law, crumbled as the world’s biggest pot calls Putin’s (pretty big) kettle black. (Diversion ended)

I do not know what happens to humanitarianism in the face of the world getting bigger and the world getting smaller. Aside from shrill press releases, what course of action to take if we believe that our access to people in crisis (Somalia, Iraq, Syria, Congo…) depends in part upon a strong respect for international law and norms? Where it concerns us, I know that we aid agencies have trumpeted ourselves as flag bearers in the international order. We are the goose too. So I know that we who define the humanitarian project must break from our own growing trends of self-interest and living in too small a world.

EF Inhumanity

Let me start off with a good old American colloquialism: It ain’t over till the fat lady sings.  Well, in terms of my career with MSF, the fat lady is warming up her voice.  After 15 years, today is my last day.  Question I am asking myself:  So, Mr. Ex-Director, what words of wisdom after all that time?  What is the big message?  What is the meaning of our MSF/humanitarian life?  Answer I keep coming to: Beats me.

Every time I feel on the verge of grasping it, waves of emails and interruptions tumble me back to the starting line.  More pertinently, waves of challenges from, well, reality.  I cannot understand why MSF was forced to withdraw from Somalia. Why a multi-billion-dollar aid industry struggles to provide a meaningful response to crisis in South Sudan. Or why easily preventable diseases tear through children in so many parts of the world.  Humanitarian action is complex.  No duh.

But there is a message. I have seen the light.  Specifically, I saw the light a few months ago, cycling to work on yet another cold, damp day in London.  I saw a pair of legs.

The owner of these legs was weaving in and out of the traffic (in this town where last year more cyclists have died than British military personnel in Afghanistan), those boxy black letters his well-inked press release about the power and peril to his left, right and rear.  It was a message for MSF, for all of us.

Let us begin with HUMANITY, since that is the simple imperative where humanitarian action itself should begin.  At once compassion for those who suffer and a declaration of our fundamental sameness.  We are one family, the family of human beings, all so very different at first glance and yet blessed with an identical, universal dignity.  The humanitarian imperative commands a bond with those who do not look or sound like us, believe in what we believe, or watch the same edition of Big Brother that we watch.  The imperative propels us towards those who suffer not out of duty to kin, friends or clan, not out of affinity to those who share our religion or nationality, but because the suffering of one affects the whole and touches us as individuals.  Because in responding to the stranger, we build our own place in the family of humanity.

On top of that, humanity has propelled me to crisis – to this career – because humanity itself is at the root of crisis.  To be sick or injured and have no access to care is bad enough.  All the worse when it is caused by or paired with violence, abuse, exclusion, oppression.  Or greed, power, hatred. Or staggering, structural poverty.  There is something compelling, challenging and sinister about that combination – of responding to crisis because something bad happened to people (e.g., rains didn’t fall) and because something wrong was perpetrated against them (e.g., displaced onto marginal lands).  Compelling because that is where MSF finds those most in need.  Challenging because being humanitarian requires more than therapeutic action.  Sinister because it transforms medical action into an act of protest against the human origins of the harm.  MSF’s very engagement levies an accusation against those who reject humanity.

And that means some people won’t like us.  And that means some won’t let us do our work.  So, MSF (not to mention the rest of the humanitarian system):  What are you going to do?  As the proficiency, ambition and impact of our medical action becomes ever greater, what will become of our commitment and courage as an organization of protest?  As governments around the world become ever more cynical and capable in their manipulation/control of humanitarian aid, as they insist that we shut our neo-colonial mouths, what course will we steer?  What choices will we make?  Establishment aid agency or rebel humanitarian?  Fractious silos of ego and power or collective voice of dissent?  Muted opinion?  Round after round of risk-averse calculation? Or “Fuck Taxis,” because that is the voice of a piece of humanity bearing witness to powerful pieces of its antithesis.  Fuck inhumanity.

Well, MSFers?  I’m leaving.  So what are you going to do? The trend may be clear, but on this key question of humanitarian identity, the fat lady has yet to sing.

[I will leave MSF but Humanicontrarian will live on for a few weeks, then take a break, and then come back fresher than ever.  I hope.]

The Case Against Idiots

Check out the new web page over at MSF UK’s website.  The Name? Opinion and Debate.  The Idea?  Put an end to corridor and lunchroom pontificators actually defining MSF policy and practice. Let’s see these ideas. And let’s debate them.

Michiel Hofman makes a great case for thinking of us expats as “useful idiots”.  The basic idea, especially relevant in conflict settings, is that expats are largely immune to the sort of local pressures that divert aid according to a personal, political or military interest.

Michiel’s piece, though, is exactly right in using the term “useful idiots”. It’s just that he draws the wrong conclusion. Of course there are pressures placed on decision-makers, and of course the safeguarding of aid’s impartiality (not to mention neutrality and independence) is vital. But what about the idiot part?

Even if we agree that they are able to pack up and go home, do expats really make a good decision-makers. Here’s a few of their common traits: (a) can’t speak the local language; (b) can’t read a local newspaper (ditto for radio, TV, etc); (c) don’t know much more about the history, culture, peoples or politics of a given context than you could find out by reading the background section of a Lonely Planet Guide; (d) don’t have an established relationship (let alone hundreds of them) with a single local person; (e) have phone contact lists full of other foreigners and aren’t trusted (nor, perhaps, distrusted) by people in power etc etc. In the end, let’s admit that a relatively high level of ignorance and blindness are at least just as inimical to objectivity and sound decision-making as are pressure and bias.

Michiel makes a great argument for expats as people who can open doors. But idiots don’t build effective houses. Worse still, they have trouble even noticing if they didn’t. In the end, rather than making a case for being useful, I’d suggest a better solution would be to get rid of the idiot. The model there? Locally empowered NGO hires a few powerless, foreign front men who provide the “protection” Michiel seeks but aren’t allowed to interfere in the development and implementation of contextually effective programming.

See No Fogeys. Hear No Fogeys. Help No Fogeys?

Ten years ago I visited our projects in Pool Province in Congo-Brazzaville.  It was during Pasteur Ntumi’s armed, mystical insurrection; a time when military groups chose videogame names like the “Cobras” or “Ninjas”.  I heard more than once that Ntumi could levitate. But that is a different story.

We lurched down the ersatz road, passing many villages. They looked quiet. They looked abandoned.  Empty, I kept being told. Empty. But they were not empty. Everyone under 45 had long bolted for the IDP camps, but the elderly hadn’t left.  Occasionally I would see a skinny man, somewhat dishevelled and gray, carrying a bundle of wood or wandering the dusty alleys between houses.

If terms of vulnerability, those community guardians must have registered off the charts.  And we weren’t touching them.  We were driving by without seeing them, or seeing their absence in our busy health clinics.

This is not uncommon.  A “neglected generation”, as HelpAge research shows. Or see here. MSF has concluded that aid programmes miss the elderly even though we all intuit their vulnerability.

It shouldn’t be that way.  Impartiality dictates to humanitarians that we make decisions based solely on the needs of people, not their life expectancy after treatment or value to society.  Attaching value to human life is inimical to humanitarian action. Ditto for medical ethics. We don’t value people based on age. Grannies are absolutely equal in value to toddlers. We don’t try to justify differentiation by arguing cost effectiveness in terms of life value.  That kind of thinking will lead you down the path to hell, to saving the owner of the factory over the workers, the teacher over the vagrant, the NGO expat over the NGO local staff.

Impartiality implies that you have done a proper assessment to identify, in this population and in this crisis, those most in need. In a place where the needs overwhelm resources, it implies choices will be made.  As the research shows, though, we don’t do a good enough job of assessing needs when it comes to the elderly.

The problem is not one of mere choices, but of the underlying subconscious preferences; of blinkers. Some of these blindspots have evolved within our work.  For example, we use shorthands to target people/areas of greatest need:  “under fives,” “IDPs,” “pregnant and lactating women” are typical proxy indicators of greatest need.  And with good reason. It is true that you will find higher burdens of needs among these target groups, or overlapping needs (e.g., sick child plus no shelter or clean water), or greater severity of needs (e.g., on average, a toddler with malaria is more at risk than an adult with malaria).  But has looking for proxies meant not seeing others?

The way our brains work, it seems that if you are focused on one thing you will not see something else.  (Here is a great test of selective attention). The elderly have different needs from those of children, and you need to look in a different way. For example, as a starting place, you need to make sure that your assessment tools are able to ‘see’ elderly people. Much of MSF data collection puts people into boxes: < 6 months, 6 months to five years, 5 – 14 years, and > 14 years. We literally lump teenagers in with octogenarians. Where else would that happen except in wedding photos?

With data like that – with the conceptualization of our target population underlying those numbers – busy teams miss those who do not arrive.  That gap in spite of understanding that elderly have special access issues. It’s sometimes really simple. If you’re sick and seventy, trekking 10 km to find healthcare is not ideal.

Research leads to calls for paying attention; for systematic consideration of the elderly in humanitarian response.  But why are the decks stacked against impartiality in the first place? One reason is the way we think about children in our own societies, and in particular the way we think about their well-being. There’s a certain tragic disposability of children in places where birth and mortality rates are high.  And in the West, a tragic overvaluation, with children raised in porcelain towers.  (See my blog on baby helmets).  Apologies, this is the slippery turf of sweeping cultural generalization, but you get what I mean.

In the end, it is not accidental that the humanitarian project prioritises children. What is the UNICEF equivalent for the elderly? There is none. Why is Save the Children so much larger than HelpAge? The quantity of Western NGO resources essentially devoted to children in other parts of the world reflects a very Western valuation of children. That institutionalization of our value system produces a certain set of programme activities, the organisations that deliver them and, ultimately, that thing we call the humanitarian system.

Inherent in those values is the feminisation and infantilisation of victimhood. Powerlessness plus victimhood equates innocence, and that underpins why people give money to a cause. You can sell starving babies – we do it all the time. Try geriatrising it.  Pause the camera on the face of an old man.  You won’t run a billion-per-year NGO on that face.

Keep it Simple, Stupid

Poor George Clooney.  He’s such a busy guy.  What with making blockbusters, Nespresso ads and all those mystery women, it’s a wonder the actor has had time to throw himself into the quagmire of Sudan.

South Sudan isn’t doing too well these days.  Arguably, the mess is George’s fault. If we hadn’t all suffered the delusion of Sudan’s bright future, we might have been busier dealing with its complex faults.  That’s what Daniel Howden insinuates.  He takes Clooney (among others) to task now that the South Sudan house of statehood has collapsed faster than Anthony Weiner’s political career.  Howden writes that “actors were highly effective at communicating a narrative about the new country that borrowed from a simple script.” That narrative (i.e., all problems were caused by the Wicked Witch of the North) was, unfortunately, “part truth, part wilful misunderstanding” and “deeply flawed”.

Let’s give George some credit. He is not a phoney when it comes to playing savior.  He didn’t just show up at a fundraising dinner, or make one self-aggrandizing visit.  The man has invested something of himself.  He even got arrested for the cause.  But there are limits to that credit.

Howden is right to call out the overly simplistic narrative, but let’s not blame actors for the superficial script.  As I’ve blogged (e.g. cleansing conflict from the ‘perfect storm’ of factors causing famine in Somalia in 2011), the entire international community – politicians, aid NGO agencies, UN officials – seems dependent upon simple scripts.  The only time we embrace complexity is in explaining our failures.  (Of course, academics ply a healthy trade in the complexity of places like Sudan, but who really listens to academics besides other academics?).

You can’t sell complexity.  No funding, no donations, and no political support.  It’s even a hard sell within an agency.  Try getting MSF to add some nuance to its analysis of Syria!  And maybe that’s not such a bad thing, given the need for action rather than endless deliberation. Complexity is a cousin of perfection – it can be an enemy of the good.

As for Clooney and the celebrification of the aid business, maybe I’ve been wrong in the past. Maybe it’s wrong to begrudge him the attention he and other celebrities get.  Sure, NGOs across the spectrum have sold out to the celebrity culture in the hope of increasing attention to our causes. But maybe celebrities really do make more effective champions than we activists.  Maybe humans are hardwired to follow the opinions of celebrities. See this article.   Apparently, it has to do with something so academic sounding as the anthropology of prestige.

How about that! Evolution has left us biologically inclined to follow the political analysis of celebs, not to mention their fashion tastes, recipes and personal grooming tips. Can somebody please get Miley Cyrus to say something about CAR?

2013: Goodbye to an Ominous Year

I have posted a rather depressing rumination on 2013.  See the Huffington Post UK site.  Here’s a teaser:

Though certainly depressing, the observation that 2013 was a bad year is fairly unimportant. More worrisome is the prospect that 2013 signals a dangerous trend, even while experts tell us there has never been so much peace in the world. I see a mounting number of places that have reached a critical mass of disrespect for international law and universal ideals, or their outright rejection; and where rudimentary compliance is no longer deemed useful.

Holiday Jeer

Painlessly short ideas for your holiday pleasure…

1. Development aid is like a kid getting a pair of goldfish for her birthday. In those first days, you can spend hours looking at the tank, watching the fish go about their business. Not much happens.  You can even talk to them, or tap on the glass.  Still, not much happens. Take a pinch of food flakes and toss it onto the surface of the water.  The fish dart to the surface and begin inhaling the flakes from underneath.  Press your forehead against the glass.  That’s better than Jacques Cousteau.

The next day your mother catches you feeding the fish again.  She warns against over feeding. But you can’t quite hold back.  You wait for your mother to disappear and then show friends how it works.  This is the thrill of your hand at work.  This is the reward and psychological satisfaction of causation.  And pretty soon your fish are belly up.

2. Good to see more awareness of the alarming persecution of homosexuality in places like Uganda, South Africa and Jamaica (e.g., here or here).  Typical reaction here is to think of that anti-gay violence as barbaric, as inherent in “their” lack of civilization.  Well, it is barbaric.  But is it something so comfortably foreign? On the news today I learned that the Queen used the Royal Prerogative of Mercy to issue a posthumous pardon for a 1952 conviction for homosexuality. British war hero (codebreaking) and mathematician Alan Turing was punished by chemical castration. Why does such a pardon require an act of mercy?  There is nothing merciful about it.  And why does it require 51 years?  As human rights campaigner Peter Tatchell opines: “I do think it’s very wrong that other men convicted of exactly the same offence are not even being given an apology, let alone a royal pardon.”

3.  Nice piece of journalism in yesterday’s Guardian (some interesting comments as well). Title: The State that Fell Apart in a Week.  Plenty of chatter in the twittersphere on the suddenness of the collapse. My own rather sarky take on it:  If it falls apart in a week, it wasn’t a state.  I’m not sure how to build a state, but you can cross ethically [oops, I meant "ethnically"] fuelled civil war off the list.  Ditto for destroying your oil industry and an outbreak of atrocities.

Without trying to sound either uncaring or self-absorbed, there is something quite telling and terrible about the impact of this emerging catastrophe on the international community.  Lots of international blood, sweat and tears, not to mention dollars, have poured into South Sudan.  It is fine to expect that the humanitarian community must once again muster a Herculean effort to feed the hungry, shelter the displaced, and set up a healthcare system; or that international militaries must enforce peace between the warring parties.  But let’s not begin with the World-has-failed-the-people-of-SouthSudan line of self-flagellation. The South Sudanese have failed themselves. And they’ve laid to waste an awful lot of hard work.

4. And because self-flagellation (or, at least, self-reflection) is often a valuable commodity … The international community constructed South Sudan’s house of cards nationhood through an almost comprehensive “partnership”.  Many will opine that the fickle finger of fault should be pointed in the direction of everyone from the UN to the US Government to all the big NGOs to George Clooney.  Many will opine that we must draw lessons and do it better in the future.  But I would go back to the goldfish story above before jumping onto the bandwagon of building a better South Sudanese state (or Somali, or Afghan, etc).

Happy Holidays

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