Health, Politics

“Pound of Cure” Politics

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Who hasn’t heard this one: An ounce of prevention is worth a pound of cure. The old adage presents a truism well relevant to the world of international aid. Ebola comes quickly to mind as the latest in a long list of lessons not learned. To wit, at what point – March? May? – would a fairly modest ten million or so have staved off the need for the $1.3B intervention that has been launched to date?

But the proverbial equation generates a false comparison. The “pound of cure” logic dissimulates. That tail of the proverb represents the cost of an intervention at a later stage – the bill for the fix (i.e., action after the problem has materialized). The mistake is to confuse the cost of the fix with the value of the damage. Pound of cure thinking hides ten, twenty or maybe thousands of pounds of loss – 11,000 orphans, schools shuttered, crops unsown or harvests unharvested, businesses bankrupted, national economic growth about-faced. And over 9600 people who are no longer people.

Let’s not be too hard on the proverb. Let’s be hard on ourselves. In the deeply politicized world of international aid and emergency response, the availability of the proverbial ounce of prevention turns out to be part mirage, hence a solid track record of paying for pounds of cure. This study of the 2011 famine in Somalia seems clear enough: Famine early warning systems clearly identified the risk of famine in South Central Somalia in 2010–2011 but timely action to prevent the onset of famine was not taken.

It too often proves more difficult from a political perspective to prevent a problem from arising than to deal later with the consequences of the problem itself. That is because mobilizing preventative action often proves trickier than launching a curative response. Humans seem hardwired to contend with the urgent at the expense of the important. In proverbial terms, that is also because frogs don’t hop out of water brought slowly to boil. And because screeching wheels get the grease before those that merely squeak. Tired yet? How about this? In the aid world, few will pay the early bird to catch the worm.

Enough of the proverbs. Let’s try fairytales. Is it even fair to balance a pound of cure against one sole ounce of prevention? What does the story of the Boy who cried “Wolf!” tell us? If not a boy, then what about the Western NGO? We belong to a business that depends on the production of a veritable smorgasbord of impending disasters; of persistent, strident calls for action (read: squeaky wheels in search of grease). That makes for a fast drip of public alarm, elbow-steered lobbying, and celebrity-endorsed impending doom. Act now! (Or: Send cash!). How many cures – how many actual crises – have actually been averted? Perhaps this is not just a tale of a Boy. Perhaps this is also the work of Chicken Little.

If we flip this around: the emergency aid business is of necessity an industry of alarm. Is there today a cacophony of alarm and media hype that deadens the ear? Have we reached the point where it is actually more efficient and more financially prudent for key donor governments and international institutions to wait and pay for the cure?

And what about the lessons of those fairytales? Cries of “Wolf!” or “The sky is falling” became quite pertinent in the Ebola crisis, where MSF’s early alarm was derided or dismissed in some quarters as yet another NGO fundraising ploy. The NGO cried out that Ebola was real and nobody listened. Real it was. A ton of cure that could have been averted by an ounce of prevention? Seems so. And maybe also a ton of cure that was necessitated by the perception of too many false ounces?

 

Health, Our Western Identity

The Hammers and Nails of Ebola

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“MSF made a big mistake.” Not a small admission from Claudia Evers, MSF’s Emergency Coordinator in Guinea. Think how much more effective international aid might be if more aid organizations publicized rather than buried such opinion. But that is another blog.

The issue is basic. In its early stages and as the Ebola outbreak mounted, MSF placed almost all its apples in the treatment basket. Fueled by the twinning of high transmission levels and the sloth-paced scaling up of treatment (MSF aside), the virus far outpaced the intervention. Evers concludes: “Instead of asking for more beds we should have been asking for more sensitization activities.”

But did MSF make a mistake? Or is this more of a design flaw in the system? Treatment is what MSF does. Treatment is what MSF is designed to do. When it comes to outbreaks like cholera, or diseases like malaria, or even ‘epidemics’ in some places like maternal mortality, MSF is a hammer of treatment. Nobody, and not even MSF, should be surprised that it sees a world of nails – people who first and foremost need treatment.

To simplify: A good buddy of mine is a cardiologist. His brother is a cardiac surgeon. They disagree bitterly on how best to deal with their aging mother’s heart problems. The former wants to manage it through drugs, diet and exercise. The latter wants to cut. The lesson is that identity determines perception.

So the problem was not MSF calling for a massive, rapid increase in beds and treatment capacity. The problem was that MSF the hammer’s voice stood virtually alone. The problem, in other words, was the absence of other tools in the kit. Where were the wrenches, NGOs that specialize in grassroots mobilization, and who would have seen its potential and pressed for it? Where were the screwdrivers who would have championed decentralized models of care? Where was the diversity of discourse?

Even as sensitization activities scaled up, local communities seem to have been viewed more as targets than as actors. One concern is that the authorities (foreign and international) installed centralized structures for the dissemination of information, rather than capitalizing on local capacities. Another claim is that messages were too simplistic: being told what not to do with a sick child does not provide an actionable solution for a mother with no access to a treatment center. What should she do?

It seems there is an emerging consensus that local communities in Sierra Leone, Liberia and Guinea were sidelined in the rush to contain Ebola, treated more as an obstacle due to their distrust and ‘primitive’ behavior (see, e.g., here). Treated then as a vector for the disease, to be contained rather than sought out as a potential partner in defeating it; not understood to be necessary to generating solutions and disseminating the word. In the end, it seems providential that they did not remain contained, and many communities took the fight against transmission into their own hands (see, e.g., here).

To recap: the Ebola outbreak response reduced communities to a combination of victim, vector, and potential security threat. Otherwise, the aid response and media coverage of it rendered these communities invisible. That invisibility comes because the entire international community – the Western governmental and NGO aid response – is deeply, messianically self-referential. That is the hammer of being a savior, and it blinds us to anything but the nail of victimhood; to the reality that many people, given the shortcomings of international aid, need to know how to save themselves. That is the hammer of being largely Western/foreign, and seeing the nail of disarray, primitivity and ignorance.

One step further: consider this piece from Oxfam CEO Mark Goldring on his recent encounters in Liberia and Sierra Leone. In a few simple paragraphs he conveys the “suffering, bravery and stoicism” of the people. Yet such narratives always fall short. Be it Syrian refugees or civilians in Central African republic or the survivors of Ebola, the sheer scale of grief, social/livelihood devastation and grinding anxiety over life itself evade our comprehension.

For all our efforts, this tremendous suffering remains beyond our ability to fathom with clarity. And it lies beyond our ability to mend. As humanitarian organizations, we find it much easier to be the hammer of crisis response, seeing the nail as the problem called hunger or shelterlessness or, in this case, outbreak. As important as it is to contain and defeat this outbreak, I wonder if we are preconditioned to see the virus, sick people to be mended, and not the millions of people who need something altogether different than the hammers of Western pity, charity, or aid.

Health, Politics

When the Pendulum Swings

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Be careful what you wish for. That is what I would tell Thomas Frieden, if ever I had an opportunity to talk to the distinguished director of the US Government’s Centers for Disease Control (CDC). While the failures which led to the Ebola epidemic must be addressed and most certainly require difficult changes, we should avoid launching the pendulum too far in the opposite direction. Over-correction can be just as dangerous as doing nothing. (Perhaps even worse if, in the long run, failed change undermines the very case for change itself.).

Speaking as the executive board of the World Health Organization voted to overhaul the organization, here is what Frieden said: “Too many times the technical is overruled by the political in W.H.O. We have to reverse that.” His comments follow the generally accepted observation that the bungled response to the outbreak was in part due to the poor quality of WHO staff in West Africa. Political appointees rather than officials with proper qualifications.

I’ll start with the obvious: Frieden appears to be right. But there is a mistaken underlying assumption – that health, disease, pandemic response constitute primarily technical challenges. This overlooks the degree to which these issues are profoundly political. So: true enough that political savvy can neither replace nor overcome a deficit of technical understanding. Even worse, what of situations where the so-called political appointees lack political savvy, meaning where they are appointed for reasons of political loyalty and ties rather than political acumen? That’s a lose – lose situation.

But Frieden’s comment ignores the opposite risk. All the technical savvy in the world may amount to very little when it hits the political wall. Better qualified WHO appointees in West Africa may have recognized much earlier the threat posed by rising Ebola cases, and may have been less concerned with offending local political sensitivities, but there would have been plenty more hurdles to cross, some of them sadly and resolutely political. Remember, before they felt the threat themselves, the greatest powers in the world chose not to respond to Ebola in this strategic backwater of a region.

My instinct tells me that Frieden comprehends this quite well, and he may be one of those rare individuals who blends technical qualifications with a significant level of political interest and ability. That is not a common combination. A case in point: the bi-annual meetings of the Executive Directors of the various MSF sections. For the six years I was ED, there was never a time when more than one of the nineteen EDs was a doctor (though we often had a number of ex-lawyers), or more than one of the operational directors, and very few of the heads of mission. Throughout the executive level of MSF, from project coordinator to director, one finds few medically qualified personnel sitting in the hierarchy of decision-makers.

This is not the place for an analysis. Suffice it to say that (1) from security management to human resource management to negotiated access, running effective emergency medical missions in places like Sudan or Haiti requires more than medical know-how and expertise; and (2) the organization has built substantial in-house medical expertise across the spectrum of its areas of intervention.  But the problem highlighted by Frieden’s quote is easier to describe than solve. In terms of the political and the technical, integrating those two bodies of knowledge, experience and focus posed a consistent challenge within MSF, and we struggled with various policies aimed at improving organizational structure and culture.

The Executive Board of WHO proposes what we sometimes termed “remedicalization” in MSF. The goal is clear: ensuring that Frieden’s “technical” sufficiently nourishes WHO analysis, decision and action. Sticking technical people into what are often politically charged jobs, though, may simply create the next crisis, the one where the pendulum has swung too far.

Our Western Identity, Politics

Lessons From Charlie Hebdo

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What do David Cameron, Angela Merkel, Benjamin Netanyahu and Mahmoud Abbas have in common? Well, probably lots of things. Here’s one you weren’t thinking of: All of them attended Sunday’s massive Charlie Hebdo rallies in Paris, and did not make any such powerful protest when the Taliban murdered 132 children in Peshawar. A number of articles (see here or here), comments and tweets have contrasted the West’s reaction to the murder of twelve satirists with the case of those Pakistani children, or Boko Haram’s abduction and enslavement of 276 Nigerian schoolgirls.

There is a sad futility in making such comparisons. First, it is not a comparison of like to like. Would the Charlie Hebdo attack have created such a global outpouring without the video footage of the gunmen making their escape? Are the Taliban not the old story, half as sexy as the Islamic State? Bottom line: lots of factors explain Sunday’s extraordinary political and emotional outpouring as 3.6 million people pinned Je Suis Charlie to their hearts.

Beyond that, though, is the misplaced anger of these accusations. It is OK to feel a greater kinship to those closer to us than to those far away. This form of tribalism may even be hardwired into us as human beings. We can still exercise the core humanitarian principle that we share an equal kinship with all humanity. So I can admit to feeling closer to editor Stephane Charbonnier or cartoonist Jean Cabut than to teacher Sofia Amjad or pupil Asad Aziz (even while imagining the school children to be ‘more innocent’ – apologies for that, but you get what I mean). The mistake is not in experiencing the bias of our own very human emotions. The mistake is to allow that bias to go unrecognized, so that it fails to be overruled.

The even larger mistake is in failing to see that the source of those biased feelings is not solely kinship. These biases – our different reactions to Charlie Hebdo versus Peshawar’s massacre – are produced by the same relations of power and privilege that nourish the Western NGO and produce biased approaches, strategies and activities. These prejudicial factors range widely, from the North-South bias in media coverage to the effective valuation of some human lives over others to the difference between the West’s position towards the right to free speech versus the right to an education. Sadly, recognition of these biases will remain spotty without genuinely more global decision makers at the top of our nominally-global aid agencies.

Lesson 2: The sense of senseless

Do not succumb to the reactive view that these killings are senseless, outbursts of psychotic madness, the work of a purely bloodthirsty fanaticism. On display are undoubtedly a purpose and a logic and the capacity of this attack to advance the personal and strategic interests of the murderers. There is a cruel win-win at play – do nothing and the Kouachi brothers’ actions will look heroic, having cowed the West into a fearful submission. Have a mass rally and, well, their actions will look heroic. After all, we were not the message audience. We are more likely its vector in the quest to “sharpen contradictions.”

I wish I were in France myself. I would have marched. But I would have known that the rally plays into the hands of the militants – adding glory to the deeds in the same way an arsonist purrs as his blaze nets a five-alarm response. And my concerns would have been with my colleagues around the world, because international NGOs continue to be seen by many as symbols of Western blasphemy. Targets.

Lesson 3: Who are we kidding?

Been asked to throw away a pot of yogurt by airport security lately? Plenty of brave talk. Lots of people tweeting Voltaire. But who are we trying to fool? Much of the West is particularly and increasingly risk-averse (see e.g. this blog or this one), and we have seen the degree to which even remote threats of harm have elicited ineffective or expensive overreactions. The Ebola panic comes to mind. So let us not be surprised if standing up for free speech quickly gives way to risk management, threat aversion, and a substantial chilling of the exercise of the right to say whatever the fuck one wants.

Lesson 4: The humanitarian culture of offense

The right to offend. The right to talk back to a parent, denounce a President, or criticize a government. The right to “speak truth to power” as so many have suggested. Freedom of speech is one of the core universal human rights. And it is one of the rights that runs most contrary to the common sense, laws, limits of accepted behavior or culture of many societies.

We know that many challenge this absolutist approach to freedom of speech. We need to look no further than our universities, where academics have found themselves policed for advancing unpopular ideas, or the growth of political correctness as muzzle. And that is in the West, the supposed champion of free speech. How does it play in the corners of the world that do not believe in such public airing of opinions or insults? Where maintaining ‘face’ holds enormous cultural currency? Where the values and needs of society trump those of the individual?

Nothing justifies murder. But what of the many places in the world where nothing justifies offensive speech? We fall easily into the rationale that it is a universal right. That is elsewhere a legal technicality, not a shared ideal. More specifically to humanitarian work, what of the many places where we regularly assert this right to offend through our public reports, our exposure of the violence and abuse of civilians in a place like Darfur or Congo?

I remember a Japanese MSF doctor, thoroughly opposed to our advocacy campaign. He had no disagreement with the facts of it, yet he felt ashamed by the public airing. Neither our insistence on universality, nor our conviction that public advocacy forms a necessary component of humanitarian action, obviate the offense of our speech. And causing offense will strike many as un-humanitarian, an act of aggression and an exercise of power no different from inking a blasphemous cartoon.

Politics

Cyber Warfare: Think about who might be next

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International cyber warfare did not begin with somebody stealing the launch codes to the nuclear arsenal on a U.S. Navy Triton submarine. It did not begin with a cabal of MIT geeksquad eco-terrorists shutting down oil production in the Arctic Circle. No, those are Hollywood story lines. In the end, international cyber warfare began with the revelation that Angelina Jolie is a “spoiled brat.” It began, funnily enough, with Hollywood itself; with a powerful movie studio pulling the release of its $42 million movie, shamed by outings of internal secrets, hurt by stolen scripts, threatened with violence. So much for The Interview.

Have you followed this story (e.g., here, here or here)? Did you feel a bit catty early on, as I did, a little too elated to see Tinseltown’s top brass squirm as their personal emails became Gawker headlines? Be careful. Here’s a test. Aside from a Hollywood studio about to poke fun at the oddball ruler of a pariah country, can you think of another Western entity, or body of entities, who might occasionally humiliate the leaders of relatively powerless countries? Who might ritually indulge in the arrogance of airing someone else’s dirty underwear? Who might just irritate some nation enough, or threaten enough reputational damage, that the allure of socking one of these self-appointed voices of global conscience in the gut might appear both justified and quite delicious?

On the surface, the Sony saga has some appeal to those of us who root for the underdog: marginalized basketcase government jumps corporate behemoth and beats them into surrender. There is glory in that. And power. We NGOs in particular should understand the apparatus at play. The North Korean government (allegedly) has rode the vehicle of celebrity to guarantee viral coverage for its story, in the process shaming the would-be shamers. I can think of a few other governments who might be interested in that kind of power, and instead of a second rate comedy being canned it might be a documentary about rape in Darfur, or a report on the deliberate destruction of health facilities in Syria.

Let’s face it, in terms of our cyber security large Western NGOs have erected far less of a fortress than a company like Sony Pictures. We are exposed. Crucially, we are easily more vulnerable than the movie biz to blackmail when public perception and trust are at stake. It wasn’t pretty, but those Sony emails certainly didn’t say anything we didn’t already think about Scott Rudin, Amy Pascal or that entire industry. The public is titillated, not abhorred, by their sneering. In contrast, what do aid execs write when nobody is looking? I’m guessing that donors contributing a million a year would not appreciate email musings refering to them as, say, egomaniacal , dandruffy pains in the ass. Not to mention direct orders to strengthen the facade that the agency is working through local partners, or the truth about bloated HQ staff travel budgets and long-running projects with little impact.

Politics

Does “Never Again” Mean Again and Again?

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Is it possible to be indifferent to the U.S. Senate report on CIA interrogation? Critics of the report warn it will provoke anti-US attacks today. My concern is that it will engender the same sort of torture in the future.

One important function of this exercise in transparency is not the unveiling of information, but the veiling of brutal, self-justified power. That function can be found in the spectacle of a country patting itself on the back for exposing its wrongdoing; for ‘coming clean’. Praise is not unworthy – it is indeed commendable for a government to declare and detail how it has offended its ideals, betrayed its people, and committed crimes against others.

At the root of revealing the truth, though, is the twofold process of re-establishing power and rebuilding the myth of exceptionalism. On the former point, President Obama is clear: these techniques did significant damage to America’s standing in the world and made it harder to pursue our interests with allies and partners. By undermining its reputation and pulling a Gillooly on human rights, the U.S. lost a core component of its global power, in the process (as I have written before) eroding the very universal ideals of which it sought to be viewed as a champion. Whatever it entails, transparency of this nature must also be understood as a substantial exercise in self-interest.

Obama again: one of the strengths that makes America exceptional is our willingness to openly confront our past. In a similar vein, Senator John McCain: we are always Americans, and different, stronger, and better than those who would destroy us. In a democracy such as the USA the ability to exercise power through violence, whether legal (war), illegal (torture) or as yet undecided (drone assassinations), depends heavily on the myth that violence carried out in the name of the demos is okay.

Here is the lasting value of this report: restoring America’s faith that it is different, that it is ruled by high ideals, that it’s not really the sort of nation that commits the sort of acts that it commits. Because America’s committing such acts rests on its ability to remain, in the eyes of its people, the greatest force for freedom and human dignity that the world has ever known (Obama). Torture and killing by others are policy, are crimes of state, are the product of inferior systems and the action of inferior people. Torture and killing by the home team are thus aberrations, exceptional, and rendered part of history through confession. The loud proclamation of “never again” already begins the process of making “again” possible.

Beyond the case of CIA interrogations, most of the really bad stuff in the world is founded upon a perverted sense of right. Even at the level of petty criminals, people manage to convince themselves that their crimes aren’t really crimes (e.g., because they are robbing the rich, or that society “owes” them for past grievances, etc.). At the more macro level, from the U.S. government to the most ‘recognized’ heinous thugs in the world, from the Lord’s Resistance Army to the Third Reich, humans have been able to cause such astonishing levels of harm only because they have managed to successfully construct a sustainable ethical framework that justifies their behaviour to significant numbers of people.

In short, it’s people who believe they are right who end up destroying us because they believe that right – that appeal to a just cause, to honor, to patriotism, to redressing past wrongs, to religious glory – then bestows upon them the right and even responsibility to destroy the lives of others. Hugo Slim explores this idea in his excellent book Killing Civilians.

I’m not sure where the above observation leads in terms of establishing a coherent principle of action. Perhaps one can merge the Biblical edict against judging others with Heisenberg’s uncertainty principle, producing a principle which says that it is impossible to be right enough to judge others sufficiently to justify violent or destructive action against them. It does not mean that we cannot feel right, and/or feel right enough take action – certainly plans to bomb civilians deserve action – it is just that the limit of any action would be the line where we cross into violence against others. We should never be certain enough of either our rightness or our special nature to justify what has become, essentially, a global litany of forced rectal feeding.

Politics

Tony Blair and Global NGOs: Not so strange bedfellows

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The verdict arrived as furiously as in Ferguson: widespread condemnation, both public and internal, for Save the Children’s decision to present Tony Blair with a humanitarian award (see e.g., here). In an act designed to beef up my own award credentials, let me be the first to perform the selfless humanitarian act of extending a hand to STC (John McTernan defended the award, so I’m not the first, but then again he is essentially a Blair protege).

The humanitarian enterprise hardly needs a further injection of public distrust. The criticism focuses primarily on the moral offense of his track record in Iraq – not quite pro-children – or as PR frontman for dictators. Others lament the ugliness of this type of NGO self-promotion rendered naked. To those complaints, let’s add the potential impact in places like Iraq, where armed groups find yet another shining example of the proximity of global NGOs to their political enemies. So much for the perception of neutrality and independence.

Yet it is too easy to mock STC’s self-inflicted wounds. The true humanitarian does not judge the wounded and sick, nor deny assistance, even if it’s all their own bloody fault. The point here is that nobody should be shocked or even surprised that STC gave Blair a big fat and very public award.

The political world requires compromise, and major NGOs, including global aid organizations, labour to make themselves part of that same political world. They do so to be effective. What about Clinton? What about the many NGOs who accept funding from the Clinton foundation? Would it be fair to say that his blind eye to genocide in Rwanda had a negative consequence or two? Or that his almost farcical abuse of power damaged women across the world? What about Obama in the future? Will his legacy of healthcare to poor Americans (or whatever social issues he takes up post-presidency) be permanently tainted by his policy of drone terror? NGOs operate in this same arena, one where compromise is both inevitable and frequent. That is not a justification. That is an explanation.

Many global NGOs establish close relationships with governments and political parties, in order to obtain vital funding and in order to affect policy change (see this 2012 blog). They pepper their offices with the ranks of ex-political figures and their boards with the establishment’s great and the good (hence the blind spot at the top of STC, who did not seeing this coming). STC and Blair have very close ties (see e.g., here).

But even if not directly co-mingling with politicians, global NGOs resemble the Blairs and Clintons of the world – amalgams of brilliant accomplishments with closets of perverse compromises. Being among the elite powers on the planet is no place for unbowed idealism (and make no mistake about the power of the global NGO, be it as a voice of moral conscience, public accuser, or in their dominant relationship to the communities they serve). That reality is a message our publics will understand, if only we stop selling them the myth, and stop selling it to ourselves.

Crucially, the backlash against STC highlights the gulf between the reality of NGO action and the image of NGOs as noble crusaders. People want to believe in NGOs. And I have a feeling this backlash is particularly dangerous because it involves the choir throwing stones at the priest – nobody can blame the Daily Mail crowd for this storm about aid. What surprises me is the degree to which this gulf lies within the organization as well. STC staff appear to be among the most vocal critics, labeling the award as a “betrayal”. Fair enough to be pissed off at the negative consequences and the hit to trust in STC (or donations), but who did they believe they were working for? Who do any of us humanitarians believe we are working for? And how necessary is it to us to maintain this belief?

Perhaps Toby Denskus says it best, commenting matter-of-factly: We can no longer rely on political activism from large, professional charities. This may not be exactly news, but it is worth a reminder: Large NGOs, charities, ‘civil society organizations’ will not be among those organizations that will rock any domestic political boats.

That is no reason to lose faith. It is a reminder that they work through reform rather than revolution, pushing the establishment to do better, helping to create a better status quo. But to ensconced within that status quo to upend it. Which is why they are part of the world of Tony Blair. If only they wouldn’t broadcast it so brazenly.

Critique of Aid, Politics

The Perils of Blind Faith

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It would be difficult to imagine a person who better combines passion with sanctimony than Bernard Kouchner. He is not self-effacing. Then again, it is his ego and talent that gave birth in part to MSF, and in part to the right to intervene on humanitarian grounds (“droit d’ingerence”), later more or less codified as the Responsibility to Protect (R2P). This entertaining interview on Al Jazeera’s Head to Head program, quite heated in parts, brings out the full Kouchner. He is insufferable and yet also bold, for instance producing an unqualified YES when asked if France should have apologized for its role in the Rwandan genocide. You don’t hear many politicians being as candid.

It’s worth watching just to see the grilling he gets, but also for his unwavering commitment to the idea of humanitarian militarism, of going in to stop the killing. Over and over, Kouchner champions the idea that when people are being killed, doing something is better than doing nothing. His belief seems unshakable, even in the face of examples like the West’s 2011 intervention in Libya, whose humanitarian cloak quickly slipped to reveal an agenda of regime change; an intervention that put Libya on the path to the unqualified violent mess of Libya today and nourished a brutal insurrection in Mali. Humanitarian? More lives lost than saved? Kouchner doesn’t just dodge that question, he seems to view it as irrelevant.

Kouchner accepts no responsibility for the negative outcomes of Western intervention. He deems interfering, even through military means, better than letting people get butchered. Is it good enough, as one of the panelists suggests, to dismiss bad outcomes on the grounds that the intent was pure? That everything else – the messes of the West’s failed state-building in Iraq or Afghanistan – is simply the law of unintended consequences? He seems equally impervious to arguments that the promise of R2P is chimerical, an attractive doctrine that works only in theory because in the real world it has and always will be used to justify self-interested political and military intervention by big powers into the affairs of little powers.

Much of this would be no more than thought-provoking for us humanitarians were it not for the fact of R2P and MSF sharing the same birthplace. Fraternal twins? Once fans of the idea, nowadays most humanitarians I know regard R2P with healthy skepticism. We are quick to recognize the political intent or neo-imperial posturing when the world powers decide to intervene somewhere, especially when based on a humanitarian imperative. And we are quick to note the hypocrisy of so many decisions to look the other way.

Contrast this with our less skeptical approach on calling for more humanitarian aid, as if it were unrelated to the right to interfere politically or militarily. On the level of and connection to power, the similarities of R2P to humanitarian action remain largely invisible to us, despite their sharing (literally, one could argue) the same DNA.

It seems right to me, unshakably right to me, that humans cannot allow other humans to be killed, to die, or to suffer without doing something. Am I as blind as is Kouchner on R2P? Why dismiss military intervention as mistaken given real politik while compassionate aid is necessitated because of real politik? Of course there are negative consequences. They do not shake our faith in the moral imperative to come to the aid of people in crisis; and in the heat of action are easy to ignore or dismiss.

Is it enough to press for more effective anticipation, monitoring and correction of negative consequences: better context analysis, a more piercing focus on the role of aid within the economy of war and openness about mistakes? All good. (Done poorly or half-heartedly, though, these control measures may even serve more to ease our doubts than to correct problems.). What about the deeper level, touching upon the model for humanitarian action, and the web of power relationships in which it rests? We humanitarians possess a profound need to feel good about our work, one that is well-insulated from challenge. What’s hiding in there?

The interview with Kouchner presents a vision of blind belief. For me, it brings these doubts to a head at about the 38 minute mark, leaving me to ponder an exchange between Kouchner and a member of the audience.

Question (from a young Kenyan woman): “…MSF’s actions are often followed by French troops. How would you react when people ask you is MSF just another engine [NGO? The word she uses is unclear] that protects French commercial interests?”

Kouchner: “You are partly right…”.

That is more than a casual sharing of DNA.

Critique of Aid, Health, Our Western Identity, Politics

5 Shots on Ebola

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1. Return of the Jedi

Oh no. Just when there was some good news – falling rates of new Ebola cases in Liberia – the Ghost of Aid Mistakes Past has returned to haunt us. Bob Geldof will launch another Band Aid rendition of “Do They Know its Christmas” (One Direction I can understand, but Elbow? – say it ain’t so).

Thankfully, the response is far from a collective sigh of relief. It is refreshing to see still more cracks in the wall of the West’s narrative on aid and Africa. As I discussed in a previous post, we can now hear the voices of “outsiders” (i.e., people who actually come from places like Liberia or Nigeria instead of people like me): challenging the bias in Ebola media coverage (reinforcing the industrial savior complex); lambasting a 60 Minutes piece that treated Liberians strictly as background props; or questioning the methods/intentions of Geldof and company.

Really, African stars should gather and launch a campaign “Do They Know its a Continent?”

That said, even this critique presumes that the 1984 version of Band Aid constituted some sort of historic success. Trashing Sir Bob for promoting an antiquated vision of Africans as helpless victims misses the tragedy of Ethiopia 1984. People were dying less from drought than from the government’s human rights violations (as concluded by Human Rights Watch). In that perverse environment, aid distributions propelled the forced relocation policies that were destroying whole communities, not to mention the more recent and controversial revelation that famine relief funds helped buy arms for rebel secessionists. (See here for David Rieff’s cogent view).

2. Useful Enemies

The outbreak of fear and hysteria in America is neither funny nor accidental. Amplified by the sheer power and influence of the US, the rest of the world should take note. Nobody is safe on the same planet as a drunken giant.

The USA’s partisan cockfighting means a disease such as Ebola cannot be tackled according to sane public policy. That is because for too many leaders, the usefulness of the virus outweighs its risk. In this case, Republicans have seized the opportunity to produce a state of froth, portraying Obama and the Democrats as soft on defense, with Ebola taking the place occupied only a few months ago by ISIS. Watch here as Roosevelt perfectly hit this nail on the head 80 years ago.

If there are ever significant numbers of Ebola cases in the US, this sort of panic, media hype and political dysfunction will have a good chance of driving the disease underground, shutting school systems, fomenting violence, etc. In other words, of causing the shit to hit the fan. That’s what I would call a frightening dry run for airborne avian flu. And in certain cases, that’s what makes American hysteria a risk factor for global outbreak and collateral economic damage.

3. Two-Thirds

Tuesday I took a break from my break and sat in on a roundtable discussion of the crisis. Twenty-five or so aid workers, government officials, academics from around London. Heaps of good analysis. Lots of experience and first hand knowledge of the situation in Liberia and Sierra Leone. And I’m not sure the entire group could have put together one solid paragraph on French-speaking Guinea. Whatever the bias – language, colonial heritage, aid policy – it marks a structural weakness in the international community.

4. Fear as Policy

Obama has sounded relatively reasonable on the Ebola front. Here’s the Prez hugging medical staff who caught Ebola, and he dispatched Samantha Power to West Africa, both important symbolic gestures which may help curb fears long enough for a little science to sink in.  Or may not. Obama may not like the paranoid response to Ebola, he may even worry that measures like quarantines really will prove to be as counter-productive as the experts say, leading to a greater likelihood of Ebola cases in America, but he can’t be too upset. America’s power, not to mention minor details like its economy and foreign policy, is constructed upon a swirling foundation of irrational fear, not of a virus but of a bewildering series of bogeymen, from Communists to Muslims to terrorism to China.  (For further analysis, see Chapter 8 of David Keen’s excellent Useful Enemies).

Having a budgetary spend greater than the next ten nations combined is not easy to justify through rational political discourse, all the more so in a country (for example) whose infant mortality rate looks more like it belongs to Guinea.  The much-discussed military-industrial complex, firmly rooted in a hysterical reaction to foreign threats, remains impervious to the reality that the security measures of today manufacture ever greater threats in the future. Ditto for the potential of quarantines to increase the likelihood of Ebola cases on American soil.

5. The Secret of Economic Success

Question: What do Las Vegas, personal injury lawsuits, Lady Gaga and Ebola-induced panic all have in common? Answer: Nobody can beat the US when it comes to a penchant for excess.

No wonder West Africa is so poor. Not enough capacity for going OTT. The citizens of Guinea, Sierra Leone and Liberia watched neighbors and family drop dead around them, and yet still didn’t believe Ebola was real. A veritable ostrich head in the sand – never a good model for economic development. With one death to date and 45% of Americans worried a family member will catch Ebola, the greatest nation on Earth more resembles a frantic chicken. That’s the sort of mania needed for a juggernaut economy.

Critique of Aid, Health, Politics

Ebola: Three Ideas (continued)

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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.

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