Tag Archives: Ebola

Friday Traffic Jam

1. The lesson of the traffic jam

The traffic situation in New Orleans tells us a great deal about the current state of the world, with humanitarians at the center.  I lived there in the late 90s. The peak hour jams were miserable. The wide cement lanes of I-10 reconstituted themselves as a parking lot full of people full of a demoralized rage. The solution was obvious — build another lane. So the traffic jams were then tripled for a few years as construction of another lane took place.  Traffic was eased. Hooray for the new lane.  And then it wasn’t: more people started driving, the developers built more homes so more people could move out to those homes . . .  A few years after the opening of the new lane? The same miserable jams, now 33 percent wider.  This is not my observation.  This is science. This is the problem of ‘induced demand’.

The humanitarian system functions as many things, and one is as a new lane. I’m not quite sure of the mechanism. Is it that human society will always tolerate a certain level of excess misery, of people in crisis due to poverty, pestilence and war that escapes our efforts at alleviation?  Greater and greater budgets, greater and greater resources, greater and greater effectiveness and yet needs still outstrip supply.  Getting on top of it (ending human need), in other words, will always remain at the horizon.  Or does the mechanism have more to do with the behavior of governments and armed actors? Those making a mess and those who are supposed to solve the messes (or prevent them in the first place) will not respond, will not take difficult action, and will not end their wars because humanitarianism relieves enough pain to reduce the pressure to act.

We do not like the old idea that humanitarianism prolongs war. But if we admit that powerful/western governments will rarely act until there is a crisis, then the lack of a crisis often means they will not act.  But this traffic effect is not a question of prolonging war. This is a question of allowing more war: this is the degree to which the delivery of humanitarian aid becomes not just a palliative or fig-leaf, not just an illusion of or substitute for difficult political action, but the degree to which it produces an effect of putting out fire with gasoline.

Can we learn from the traffic jam? Here is what the research proved. The answer to the paradox of why building more lanes actually makes traffic worse has to do with what roads allow people to do: move around.  More roads = more moving around. That raises a question: what does humanitarian action allow people (politicians, soldiers, refugees, donors, aid workers) to do?  Even more intriguing, here is another finding of the researcher: if you take away lanes, it doesn’t create a big snarling mess. People adjust and the amount of jam stays about the same. In humanitarian terms, that would be a very good thing.

2. You can’t make this stuff up.

There are some quotes that seem better placed in a Peter Sellers movie. Here is Philip Hammond, UK Foreign Secretary, speaking in the aftermath of the Chilcot Inquiry on whether or not the UK made too hasty a withdrawal from Iraq.  “Maybe it was too great an ambition to dismantle quite a sophisticated country with a long-established civilisation, traditions and culture of its own, and to recreate a mid-Atlantic construct of what government should look like, often going against the grain of local culture and tradition.”

The word ‘great’ seems mildly out of place.  One could easily sub ‘monumentally misguided’. Does that ambition not seem familiar, though, to anyone in the international aid community?

3. Risk aversion or neurosis?

Has anybody ever measured the cumulative effect on our culture of entire nations singing their children to sleep with Rock-a-Bye Baby?  Hundreds of millions of admonitions pouring into the infant brain “When the bough breaks, the cradle will fall, and down will come baby, cradle and all.”  Seems like a recipe for creating a nation of  neurotics. Evidence of this mass insecurity? The mass hysteria that Ebola provoked in the USA? Our collective overestimation and overreaction to the threat of terrorism? Well, here’s more evidence, in an advert I just saw.

Living Fearless

Apparently, we now reside live in a world where living fearless is thought to include that old daredevil pursuit of tasting lettuce at what appears to be a posh street market.  Be afraid. Be very afraid. Said the spider to the fly?

 

A Political Economy of Aid Reform?

The IRC has recently released a study of reports on studies of the Ebola crisis. Their conclusion is that these reports ‘offer valuable solutions, but they also perpetuate problems by ignoring fundamental realities.’  That is because these reports ‘reflect a persistent weakness of the global conversation about health systems: the erasing of politics.’  And now, for a bit of shameless self-promotion, IRC singled out our ODI report for not falling into this trap, for correctly saying ‘what most reports, and indeed most health systems efforts, failed to recognize: that any effort to improve health systems can only succeed if it is based on an understanding of the politics involved.’

What does the Ebola response tell us about the World Humanitarian Summit?

The fast-approaching World Humanitarian Summit holds the promise of a better humanitarianism, meaning it also holds the risk of repeating the same mistakes that have doomed so many of our good intentions in the past. Of course, there are multiple mistakes that undermine implementation of the humanitarian imperative. Shortcomings and gaps as well. Not multiple, but thousands.  But in some ways, there is only one mistake that needs fixing. We need to replace talking about what we should do with talking about how to do it. And in particular, how to do it given the incentives, architecture, political dynamics and culture which govern the ecosystem of humanitarian aid.

Thus far, and the Ban Ki Moon’s recently released report reinforces this weakness, the Summit process has traded more heavily in attractive ideas than in an analysis of how history might avoid repeating itself.  New and intriguing recommendations surface, and yet they resemble the sector’s standard recommendations, conclusions and lessons learned in the degree that their feasibility is wishful. As the UNSG admits, the measures he proposes are not new, a “testament to the failure to learn from the past and to embrace necessity and change more forcefully.”  (UNSG ¶170).  It does not help that the UN’s #1 humanitarian, ERC Stephen O’Brien, has proclaimed that the system is ‘broke’ but ‘is not broken.’

How do we change our stripes? By ending the gravy train of funding for technical evaluations, dismissing rather than embracing so-called ‘lessons learned’ approaches (see here for one of my previous blogs on lessons identified but not learned), and basing analysis on a thorough political economy of the given situation.  In other words, at the system level and at the organization or project level, stop promoting reforms based on an overly simplistic understanding of the problem. Top aid thinkers Ben Ramalingam and John Mitchell explain it a lot better than I could:

Two broad sets of reasons for this lack of change are widely cited. One is that there are many drivers of change for the sector, of which the reform agenda is only one. Reforms, moreover, are seldom, if ever, the most prominent of the internal drivers. Others include organisational interests, professional norms, donor interests and so on. These serve to reinforce the status quo of the sector. … The second set of reasons relates to the reform efforts themselves. Seldom have change and reform efforts attempted to change the fundamental rules and incentives that underpin humanitarian aid effectiveness.

The paramount question is whether we will do better in the future by examining how and why we failed in the past, replacing the question of what do we want to achieve.  In this regard, the Ebola outbreak and response signaled (once again) the need for a more transformative agenda, one that avoids wishfully imagining the dawn of a new age where global public good trumps political self-interest, and instead addresses both the shortcomings of humanitarian action as well as their underlying causes.

Ebola: Lessons not learned

[Thanks to Aid Leap for publishing this on their website. Check it out here, along with lots of excellent thinking on aid.]

Tomorrow will mark 42 days since the last new case of Ebola in Sierra Leone, meaning the country will join Liberia in being declared Ebola-free. That brings the world one step closer to a victory over Ebola the killer.

But Ebola has another identity – messenger. We listened. It told us that many aspects of the international aid system are not fit for purpose. Many – too many – of the problems the outbreak revealed are depressingly familiar to us.

Pre-Ebola health systems in Sierra Leone, Guinea and Liberia were quickly overwhelmed and lacked even basic capacity to cope with the outbreak. The World Health Organisation (WHO) failed to recognise the epidemic and lead the response, and international action was late. Early messaging around the disease was ineffective and counterproductive. There was a profound lack of community engagement, particularly early on. Trained personnel were scarce, humanitarian logistics capacity was insufficient and UN coordination and leadership were poor.

The lessons learned should also come as no surprise: rebuild health systems and invest in a ‘Marshall Plan’ for development; make the WHO a truly robust transnational health agency and improve early warning systems; release funds earlier and make contracts more flexible; highlight what communities can do, and engage with them earlier. Except these lessons learned haven’t really been learned at all: they are lessonsidentified repeatedly over the past decades, but not learned. 

Why is the system almost perfectly impervious to certain lessons despite everyone’s good intentions? The short answer: these lessons are too simplistic. They pretend that the problem is an oversight, a mistake to be corrected, when in fact the system is working as it is ‘designed’ to work.  The long answer: what is it about the politics, architecture and culture driving the aid system that stops these lessons from becoming reality?

Take a simple idea, like reconstituting the WHO as an intragovernmental agency with a robust mandate to safeguard global public health, and the power to stop an outbreak like Ebola. Sounds great, but not new. So it also sounds like wishful thinking. It does not address the inherent tension between sovereignty and transnational institutions.

Think of it this way: the more robust an institution, the more of a threat it poses to the individual states that are its members, and hence the greater incentive for those states to set limits to its power. WHO was ‘designed’ not to ruffle feathers.

A robust WHO? Can you imagine the WHO ordering the US or UK governments to end counterproductive measures such as quarantining returned Ebola health workers or banning airline flights to stricken countries? It will never happen.

Here is the true lesson to be learned: at a time of public fear and insecurity, it would be political suicide for any government to allow such external interference. The problem isn’t the institution, it only looks like it is; the problem is the governments that comprise it. That is not to say that WHO cannot and should not be improved. It is to say that the solution proposed cannot address the fundamental problem.

Or take a complex idea, such as community engagement. Our Ebola research found that the ‘early stages of the surge did not prioritise such engagement or capitalise on affected communities as a resource’, a serious omission that ultimately contributed to the spread of the disease, and hence a key lesson learned (see e.g., this Oxfam article).

Disturbingly, this is a lesson with a long history. Here, for example, is what the Inter-Agency Standing Committee (IASC) found in evaluating the international response to the 2010 earthquake in Haiti. The relevance, virtually word for word, to the situation in West Africa speaks for itself:

The international humanitarian community – with the exception of the organisations already established in Haiti for some time – did not adequately engage with national organizations, civil society, and local authorities. These critically-important partners were therefore not included in strategizing on the response operation, and international actors could not benefit from their extensive capacities, local knowledge, and cultural understanding … This is not a new observation. Exclusion of parts of the population in one way or another from relief activities is mentioned in numerous reports and evaluations.

Why is this lesson so often repeated and so often not learned? Does the answer lie in an aid culture where ‘taking the time to stop and think – to comprehend via dialogue, engagement and sociological research – runs counter to the humanitarian impulse to act’? Our report also discusses a greater concern: the degree to which people in West Africa were treated ‘as a problem – a security risk, culture-bound, unscientific – to be overcome’. 

The ‘oversight’ is hardly an oversight: people in stricken communities ‘were stereotyped as irrational, fearful, violent and primitive; too ignorant to change; victims of their own culture, in need of saving by outsiders’. Perhaps that clash of cultures highlights why we should not expect community engagement to spontaneously break out simply because the problem has been recognised.

Powerful forces work against aid actors engaging with the community during an emergency, leaving us with a lesson that has not been learned even after years of anguished ‘never again’ promises to do better.

Lessons learned are where our analysis of the power dynamics and culture of the international aid system should begin, not where it ends.

No Time to Rejoice

Hip hip hooray? The British government has announced it will welcome thousands of Syrian refugees, an abrupt reversal of fortunes for those dreaming of barbed wire boundaries.  So much for the previous day’s logic that the UK’s generous aid / involvement ‘over there’ somehow cancelled out legal and moral obligations right here.  It would be difficult to concoct a more perfect example of abusing the purpose of aid.

There are many who will view this as a victory of politics, a democracy where the voice of the people was heard.  It is certainly a case where the shift in public opinion, not to mention the shame of having even the likes of Nigel Farage (UK’s anti-immigration demagogue) call on the government to do more for the refugees, prompted better policy. But this remains a political failing.

What do Aylan Kurdi and Thomas Eric Duncan have in common?  They are both dead.  And their deaths changed public opinion.  And so their deaths changed prime ministerial / presidential policy.  That is the problem with democracy, its inability to act against the will of the people when the will of the people is too slow to embrace what is right.  David Cameron has long known what is right – legally and morally – in terms of those seeking asylum from Syria, or places like Eritrea, Yemen and Libya.

Both Cameron and Barack Obama knew that their countries needed to launch an urgent response to Ebola long before their catastrophically late (September 2014) interventions.  But they could not act because the increasingly deadly combination of the high stakes of power plus the brutal oppositionalism of domestic politics means that politicians cannot afford to act in accordance with necessity, principles, or even in line with their own moral compass.  When it comes to these sorts of foreign policy issues, it means they must wait for the public because they will not sacrifice political capital to lead the public. So they watched Syrians drown and Sierra Leoneans perish.  We all watched.

Political (and financial) dynamics thus twist the financial and proverbial logic, creating a structural preference for pounds of ‘cure’ rather than ounces of ‘prevention’. In other words, for late intervention, after the weight of a crisis has gained sufficient media attention to tip public sympathy.  The well-foreseen, slow-onset 2011 famine in south central Somalia provides a well-documented example. The humanitarian community needed those images of starving children to unblock funding, many fatal months late.  It is not a victory when doing what’s right in the face of (impending) crisis means waiting for the likes of the crumpled little boy on the beach or the feverish Liberian man in a Dallas hospital.

Ebola the lens: What do we see?

[This blog was first posted at the great Humanitarian Practice Network.  The research paper is expected this summer and will be co-written by Caitlin Wake.]

Saying goodbye to MSF’s Head of Mission in Liberia and thanking her for hosting me during my research visit. As I leaned in for the double cheek kiss that we Anglophone aid workers are so fond of displaying – a badge of cool and humanitarian familiarity that breaks with the sterility of the brisk American handshake – she leaned back. Her face was slightly horrified, her expression confused. Even as I leaned in further, confused myself and self-conscious of making a mistake, she pulled another step back. And then it clicked: No Touch Policy.

There you have it. One small perversity of the Ebola outbreak. One small particularity in a field of many, and yet also representative of a human crisis where humans are prohibited from touching one another in their blackest moments of need, fear and grief. The sanctioned protocol of bumping elbows – or perhaps fists – just doesn’t allow for the level of human connection that people working in such an unforgiving setting deserve.

A plethora of differences set the humanitarian intervention in West Africa apart from those mounted in response to other major crises, whether in Haiti, Syria or the Central African Republic. Some might find that reason enough to question the wisdom of a research project that aims to draw out lessons for future emergency responses from a black swan of a crisis. I would argue just the opposite – by catching the humanitarian aid system off balance, the Ebola epidemic has thrown the system into high relief, magnifying both strengths and weaknesses that might otherwise have gone unnoticed.

The goal of my research with ODI’s Humanitarian Policy Group (HPG) is to use the international response to the Ebola outbreak in West Africa as a critical lens for scrutinising the ‘humanitarian aid system’ as a whole. We hope to avoid duplicating the multiplicity of other assessments, evaluations and reports by focusing on the big picture, at how the fundamental contours of the aid system result in advantages, as well as shortcomings or gaps. We are interested in the power dynamics which govern the aid system’s architecture, culture and identity, and how these shaped the intervention. Hopefully, this research will contribute to ongoing efforts to improve the system’s response capacity, such as informing HPG’s position towards next year’s World Humanitarian Summit.

For now, though, we must come to terms with the immensity and unprecedented nature of the response, which was not just a colossal humanitarian deployment but also a military and scientific one. To begin with, many viewed this solely as a health emergency, some still do. But when was the last time the aid system confronted a ‘health crisis’ that decapitated local health system systems, shut down schools, postponed elections, gutted economies and shook the stability of nations? Sounds more like a classic complex emergency. Yet beyond MSF and a few specialist NGOs, we consistently hear the same refrain: “We wanted to do something but we didn’t know what to do. We aren’t medical. And we were frightened. Really frightened.” Not the best of starting points for what has become a billion-dollar intervention.

Understanding these dynamics and comprehending how an aid system that was so woefully slow to react has managed to produce such a broad, creative response is part of our task. As is figuring out why some of the mistakes made amount to an almost clichéd repetition of blunders that we have seen over and over again. Do we really need a piece of research to tell us that we are better at identifying lessons learned than implementing them?

The Old Switcheroo

It is difficult to issue a thoughtful mea culpa message and still manage to undermine your credibility. WHO just pulled off that rare double. In short, they posted their message and then replaced it with another, toned-down version. As if the world wouldn’t notice! Sarah Boseley’s blog captures the changes.

The contents should be well-received, in either version. Admitting that it has learned lessons of humility, fragility and (ironically) the need for clear communication – hard to disagree. And it is not the fact of the old switcheroo that bothers me; nor even the innocence in believing that one could slip this by without being caught. No, what I find so depressing is that in all the lessons forced onto the organization by its Ebola response, perhaps the most important has been missed.

I cannot be certain why WHO has toned-down its message, or felt so compelled to do so that it pulled the switcheroo. Somewhere, though, it seems likely that the problem was having rankled some feathers. Some people didn’t like the message, and they weren’t little people. So it had to unrankle them.

And that is the problem. That is precisely what was missing in WHO’s failure to sound the alarm, loudly and early, on this outbreak – the willingness to take the heat for making a call that would have been unpopular with those in power. Humility, fragility, capacity, solidarity… all worthy lessons. But if WHO is to become a force for global epidemic response, it must learn the lesson of rankling feathers. Take a lesson from MSF: It must learn to piss people off.

The Product of Systems

Who is in charge? Part 1.

The richest 1% of the world will soon have a greater share of the world’s wealth than the other 99%. With that eye-catcher of a stat, Oxfam launched a report and a discussion on extreme global inequality. Great stuff. Do not let the quibbling distract you. This is a street child face down on a busy sidewalk in a pool of excrement. Trust your gut: imbalance on this scale is inherently and dramatically wrong. The only debate should be which is worse – what this says about wealth distribution or what this says about power.

But what if I told you that I just read about a place where the richest few control 99.8% of the wealth? Not 48%, as Oxfam’s report denounces, but the whole enchilada? Ninety-nine point eight percent represents an astounding achievement in disparity. Can you guess where? No, not mega-corrupt states like Angola or Equatorial Guinea. No, not the petrol-rich like Qatar or Bahrain. No, not even Mark Zuckerberg’s family. Give up?

The surprise winner of the award for the most inequitable distribution of wealth and control on the planet is none other than us, the ensemble of humanitarian NGOs. Congrats to the likes of MSF and Save and (of course) Oxfam. Here’s Development Initiative’s excellent financial analysis of the humanitarian system (see p. 55ff): National and local NGOs form an essential part of the humanitarian response, but in 2013 only directly received US$49 million – just 0.2% of the total international humanitarian response. That’s US$49M out of about $2.3 billion hitting NGO coffers worldwide.

You can quibble with that figure – it’s not counting indirect flows to national NGOs – but my advice is to trust your gut. Eat your heart out, Donald Trump.

Who is in charge? Part 2

Bill Gates talks solutions. Bill Gates is right. Bill Gates calling for “germ games”. Bill Gates is all over my Twitter feed.

Gates has published an Op-Ed in the New York Times, an article in the New England Medical Journal and done a lot of media work to proclaim that good old human “ingenuity and innovation” can avoid the next Ebola disaster.

Gates makes sense, of course, calling for the development of vaccines, for better surveillance, for a global logistical and medical epidemic response capacity. Gates’ central point, though, is only half correct, and therein lies the flaw in his cunning plan. Gates claims (NYT piece): The problem isn’t so much that the system didn’t work well enough. The problem is that we hardly have a system at all.

Really? Is it that the system doesn’t exist? Or is it that the non-system of epidemic response is the direct product of another system, a highly inequitable international system of interests and power that does not typically place the public good as its paramount ambition? In other words, the very same international system upon whom Gates calls to act.

On one level, Gates forgets what happens to good ideas when their basis for attention and funding is fear and insecurity. What happens when you employ scaremongering to mobilize politicians and Western publics into funding better healthcare systems for the world? My guess: skewed priorities (epidemiological surveillance trumps maternal mortality) and unforeseen consequences, like helping to justify military expansion into global health and humanitarian action. It has not exactly served the lofty goals of international development to have become an integral tool in the global war on terror.

Most importantly, though, Gates seems to be addressing symptoms, not causes. In calling for an international epidemic response system, Gates essentially advocates the same superpower and global institutional approach that helped deliver WHO’s ineffectiveness, Sierra Leone’s woefully inadequate healthcare, or an Ebola response in West Africa that was too late, too slow and too focused on staunching the Westward flow of Ebola rather than healing those who already had it.

Bill Gates outlines a system the world needs to build. Dead right. Now he needs to outline the world that will build it, because he is silent on the need for changes in the way global institutions are conceived, controlled and built in the first place.

“Pound of Cure” Politics

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?

 

The Hammers and Nails of Ebola

“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.

When the Pendulum Swings

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.