--------------------------------------------------------------------------------------------------------------------------------------------------Friends of MSF Essay Competition 2009-10 | Category 2 ‘Theoretical and Philosophical’ ---------------------------------------------------------------------------------------------------------------------------------------------------
Shortlisted On the future of medical humanitarian aid Deepak Chandrasekharan
The 21st century has ushered in evidence-based medicine, with objective clinical trial derived answers to aid in medical decision-making. However, medicine on a global scale is less amenable to such clear-cut analysis. The underlying reasons include the striking disparity in care provision with the worst off fifth of the global population served by only 2% of the world’s physicians. As such, much care provided in low-income countries is on a short-term basis by outreach programs, often, but not always, in response to crises such as conflict and natural disasters, with the aim of immediate alleviation of suffering and saving lives. Termed humanitarian aid, care of this nature was pioneered by Henry Durant and the formation of the Red Cross in 1863. The subsequent formation of Médecins Sans Frontières in 1971 owing to differences in the ethos of reportage revolutionised the ideology of humanitarian aid. However, the ever-evolving political and philosophical issues raise questions as to the nature and role of humanitarian aid today. By considering the applicability of the underlying ideologies of humanitarian aid in modern global health, together with the increasing interplay between state and nongovernmental organisations, we will see that the nature of humanitarian aid provision will need to change to ensure the long-term survival of both the organisations, and more importantly, of the people for whom they care. The applicability of humanitarian aid The ideology of humanitarian aid relies on three tenets - providing short-term immediate relief from suffering to whomsoever requires, acting independently from governments, and impartially reporting what is witnessed. The necessity could arise from natural disasters, conflict or simply an overwhelming need for medical care as there is an insufficient domestic service. Inherent in this ideology was an assumed right and duty to
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intervene in the internal affairs of nations. The popularity and success of humanitarian aid, both in emergency and non-emergency settings, has in part meant that the tree is outgrowing its roots. In addition to the increasingly complex geopolitical situations, the scale of the current global humanitarian need is vast. UN statistics estimate 16 million refugees worldwide, 51 million people displaced within their own countries (26 million displaced by armed conflict, and 25 million by natural disasters) and 90 million people in need of food, with 54 million in Africa alone (World Food Program). Clearly the methodology and ideology of humanitarian aid provision need to change. What causes the crisis? Medical aid is needed where healthcare is lacking. This situation could arise in an emergency setting, or alternatively, it could be the normal situation in a low-income nation. As already highlighted, the disparity in healthcare between high-income and lowincome nations is vast. It is clear that whilst short-term humanitarian aid non-emergency settings helps maintain the status quo, it can never have a significant long-term effect with the simple transposition of medics and resources becoming increasingly inappropriate.
Clearly other solutions must be sought. In addition, data is now
unequivocally demonstrating how emergency aid cannot be thought of independently from aid to alleviate the causes of conflict and poverty. Two earthquakes occurred in May 2003 a few days apart. The first of magnitude 6.2 killed over 3000 people; the second of magnitude resulted in no deaths. The first was in Algeria, GDP $174 billion, and the second in Japan, GDP $4.91 trillion. The maps below highlight this relationship further. Poverty increases the impact disasters have, thereby requiring more emergency aid, and furthermore prevent an effective local healthcare service, thereby exacerbating need.
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World maps of GDP (above) and deaths caused by disaster (below). Above. Territory size shows the proportion of worldwide wealth, that is Gross Domestic Product based on exchange rates with the US$, that is found there. Below. Territory size shows the proportion of all deaths caused by disasters, which overwhelm local resources, that died there 1975-2004. It includes outbreaks of infectious diseases not normally found there. (Worldmapper.com)
Is humanitarian aid the helpful panacea we once thought for nations without healthcare? Not necessarily, Bernard Hours suggests “The ideology of aid uses distress to mask injustice… This way of dealing with disaster contributes to a global apartheid.”1 Whilst the factors necessitating humanitarian aid are attributable to more systemic problems of global polarisation, this suggestion that providing aid is thus immoral as it perpetuates the situation have only theoretical applications. As Rieff argues, “What should be the issue is what is the calculus about in the real world of how much harm one is doing, not a calculus about how in an ideal world one might do a lot better.2” The counterargument though is that as it is easier to provide aid than longer-term measures, humanitarianism precludes from ever considering the alternative solutions3. What must be made clear at this point is the difference between humanitarian aid in response to emergency settings (i.e. natural disasters, conflicts etc.) and in response to a lack of healthcare provision on a day-to-day basis. With even nations like the USA struggling in emergency settings (e.g. the New Orleans floods), the role of humanitarian aid organisations in such a situation will be necessary in the foreseeable future4. However, the role of humanitarian aid in remedying the everyday inequalities in healthcare provision is more difficult to elucidate. Many aid organisations such as MSF have made clear they provide humanitarian aid, not developmental aid, arguing the latter makes some sacrifices in the present for future benefits. However, there is compelling evidence that short-term outreach programs [in non-emergency settings] cannot have long-term benefits and are in effect, ineffective palliation. What is necessary therefore is a unifying teleological ethos for humanitarian aid taking into account these differences. The question of who is responsible for enforcing this
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ethos leads to debates of governmental independence and the second tenet of the ideology.
Independence from government Humanitarian aid has always been fiercely impartial and removed from government. Whilst organisations affiliated with the UN and governments exist, major players such as International Red Cross, MSF and MĂŠdecins du Monde remain staunchly independent. Yet the deontological ideals driving this independence may be compromising achievement of goals. This is for three main reasons. Firstly, the automatic immunity afforded to aid workers is less prevalent, with only 77 killed in 1997, but 174 in 2005 (Humanitarian Policy Group statistics, see graph.) The corollary to this argument, put forth by Micheletti, is that association with governments is responsible for these attacks and NGOs must strive to distinguish themselves from governmental aid5.
Number of Aid Workers Killed 200 180 160 140 120 100 80 60 40 20 0 1996
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Secondly, the level of funding required for NGOs to make a difference in resource-poor settings is large, and whilst certain organisations such as the IRC, MSF and MDM succeed, many others do not. The largest humanitarian donors in absolute terms in 2006 were the US ($3 billion), the European community ($1.2 billion), the UK ($1.1
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billion), Germany ($594 million) and the Netherlands ($537 million) and despite the funds entering a central pot, the involvement of governments cannot be denied6. Finally, disparate policies addressing humanitarian aid may reduce the impact of what might be achieved if a coherent aim were established. Greenaway raises the issues of donations explaining that whilst public support may dwindle if it were made clearer that humanitarianism could do more than quick-fixes or were associated with governments, they may equally increase as the “greater coherence might contribute to dissipating cynicism” 7. Before we end on the second tenet, it is necessary to consider a closely linked issue.
Right to intervene8 Let us accept that humanitarian aid can benefit global health. A premise of humanitarian aid is the “creation of victims whom you can save. Then you assert the right to have access to these victims.1” The Burmese government’s recent reluctance to accept aid has highlighted the difficulty of answering whether humanitarian aid organisations have a right to intervene. Changes in the global political hierarchy means that now more than ever, it is necessary to have a worldwide higher organisation mandate intervention by humanitarian agencies. The UN Charter makes clear the principle of non-interference to ensure international relations. Whilst provision is made for conflict situations, natural disasters are not mentioned. Likewise, the Geneva Convention states that humanitarian aid should not be considered ‘interference.’ The most vocal proponents of a ‘duty to interfere’ are Bernard Kouchner and Mario Pettati, arguing for humanitarian organisations at a conference on law and humanitarian morality in 1989. This situation once again exemplifies the difference between theory and practice. It is easy to argue about the impartiality and benefits of humanitarian aid on paper, but Hours points out, humans are territorial creatures, and it is difficult to devolve aid completely from interference1. It is likely that far from being simplified, this situation will become more complex with changes in the global political climate. The relationship between humanitarian organisations and governments will have to exist at some level, but without compromising the provision of aid. As Kouchner highlights, “In between theory and practice is a very important field called politics.9” It is up to aid organisations to ensure that politics are used as a bridge towards practice, rather than a hindrance.
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A new role – the humanitarian educator With all these issues, what role could and should humanitarian aid agencies play in the modern world? Doubtless, emergency aid in times of crisis will still be necessary for the foreseeable future. However, in the longer term, it is imperative that the focus of medical work changes to education and research. It is agreeable that the long-term aim should be one of developing sustainable domestic healthcare services. Aid agencies therefore need to work in consort with local institutions, facilitating learning and advocacy. Innovative techniques such as task-shifting (in which a lower cadre perform a service to allow it to happen10) and cascading knowledge can be used to maximise the impact. Training of non-physician anaesthetists in Haiti by MSF11 has proved very successful as has the Primary Trauma Care initiative. In addition, research relevant to conditions in resource-poor nations will help highlight the extent of the problem, and allow an evidence base for not only the treatments, but also the methodology by which they are provided. Research is also required to publicise and quantify the disparity in care and the true extent of need12-14. A contentious issue related to this is one of témoignage, the impartial and objective witnessing and reporting of events when on missions. MSF have pioneered this and their view is in contrast to the Red Cross policy of silence. The full discussion of this is outside the scope of this essay, but from a personal viewpoint, humanitarian aid is concerned with helping those in need, and publicising of plight is as important as the healthcare provided. The future Humanitarianism has evolved a great deal over the years and it must continue to do so. With increased technology and resources, high-income nations have the opportunity to do a great deal more than relief alone with humanitarian crises. As highlighted in this essay however, whilst the underlying drive to help others is an ivory tower of altruism, the battle facing us in the modern world is how to make this tower accessible at ground level. The future will see a blurring of the boundaries between humanitarian aid and developmental aid, with such semantic debates becoming more irrelevant. There must be an increased emphasis on creating and implementing sustainable methods of delivering aid. Likewise, when considering the four stages of a project ‘Assessment, Initiation, Running and Closing,’ the closing stages must become more important. Furthermore, with the advent of the Humanitarian Accountability Partnership in 2003,
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humanitarian aid will also be regarded a health intervention, with auditing and evaluation of missions to ensure best practice. To finish, humanitarian aid came into existence out of necessity. It is not an end in itself but purely a means towards providing universal healthcare for all. In the debates that the future will hold, this should not be forgotten, else we also forget the very people we are fighting to care for. Word count: 1931
References 1. Hours, B. NGOs and the victim industry. Le Monde Diplomatique. 2008, November. 2. Rieff, D., Myers, J. A Bed for the Night: Humanitarianism in Crisis. Carnegie Council Ethics in International Policy Meeting Transcript. 2002 January 3. Kaldor, M. New and Old Wars : Organized Violence in a Global Era, Cambridge UK. 1999 4. Chu K, Rosseel P, Trelles M, Gielis P. Surgeons Without Borders: A Brief History of Surgery at MÊdecins Sans Frontières. World J Surg. 2009 Aug. 5. Micheletti, P. World without frontiers. Le Monde Diplomatique 2008, November. 6. http://www.globalhumanitarianassistance.org Accessed 2009. 7. Greenaway, S (2000) Post-Modern Conflict and Humanitarian Action: Questioning the Paradigm. Journal of Humanitarian Assistance, January. 8. Fleuriot, C (2008) A right to intervene. Le Monde Diplomatique. 2008/11 9. Kouchner, B., Rosenthal J.H, Cox, M-L. The Future of Humanitarianism. 23rd Annual Morgenthau Memorial Lecture on Ethics and Foreign Policy. Carnegie Council Ethics in International Policy Meeting Transcript. 2004 10. Chu K, Rosseel P, Gielis P, Ford N. Surgical task shifting in Sub-Saharan Africa. PLoS Med. 2009 May;6(5):e1000078. 11. Rosseel P, Trelles M, Guilavogui S, Ford N, Chu K. Ten Years of Experience Training Non-Physician Anesthesia Providers in Haiti. World J Surg. 2009 Aug. 12. Ford N, Nachega J, Engel M, Mills E. Directly observed antiretroviral therapy: a systematic review and meta-analysis of randomised clinical trials. Lancet. 2009 Nov.
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13. Gosselin R, Maldonado A, Elder G. Comparative Cost-Effectiveness Analysis of Two MSF Surgical Trauma Centers. World J Surg. 2009 Sep. 14. Zachariah R, Harries A, Ishikawa N, Rieder H, Bissell K, Laserson K, et al. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2009 Nov;9(11):711-7.
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