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Toward Resilience:
Goldilocks Had It Right: How to Build Resilient Societies in the 21st Century
›By Laurie Mazur // Tuesday, March 5, 2013
‘Toward Resilience’ is a series on the meaning of global resilience and vulnerability today.
When Superstorm Sandy slammed into the U.S. East Coast last October, it was the latest in a series of “teachable moments” about our growing vulnerability to climate change.
The storm killed some 150 people in the United States, and wrought upwards of $50 billion in damage. Moreover, by temporarily disabling New York City – one of the great financial and cultural capitals of the world – the storm seemed to jolt many out of denial. “It’s Global Warming, Stupid!” blared a headline in Bloomberg Business Week. And, after a long silence on the subject, President Obama acknowledged climate impacts in his inaugural address. “Some may still deny the overwhelming judgment of science,” he declared, “but none can avoid the devastating impact of raging fires and crippling drought and more powerful storms.”
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From the Wilson Center:
After the Disaster: Rebuilding Communities
›By Lauren Herzer // Thursday, April 12, 2012Recent history has shown that no country, developed or developing, is immune to the effects of a natural disaster. The catastrophic tsunami that struck Indonesia in 2004, the earthquake and subsequent tsunami that struck Japan in 2011, the 2010 earthquake in Haiti, and Hurricane Katrina in the United States in 2005, are all reminders of the deep and long-lasting impacts that disasters can have from the local neighborhood all the way up to the national level. Each of these disasters also garnered international attention and response, showing that globalization is a game-changer in the worldwide response to community or regional-level crises.MORE
And yet, as evidenced by the continued challenges faced by each of the places above, the disaster response community still struggles with how to contribute most effectively to local level recovery. Recognizing this, the Wilson Center’s Comparative Urban Studies Project and Environmental Change and Security Program, and the Fetzer Institute recently brought together an international group of practitioners, policymakers, community leaders, and scholars to identify best practices and policy in disaster response that are based on community engagement. A subsequent publication, After the Disaster: Rebuilding Communities, highlights the complex nature of disaster response and explores ways to overcome the inherent tension between those responding to disasters and the local community.
Voice, Space, Safety, and Time
A key theme that emerged during the workshop was the importance of identifying the strengths of the post-disaster community and building responses based on those. So how can one identify the strengths of a community? In a previous Wilson Center/Fetzer Institute workshop on community resilience, participants emphasized the importance of civil society voice; the creation of space, both physical and political; and the assurance of safety and time.
Not surprisingly, all of these aspects of resilience emerged in the post-disaster response discussion as avenues to access the strengths of a community. Finding and listening to the voices of the community, identifying the physical spaces or “centers of gravity” around which the community operates (often spiritual and cultural activities, or gatherings that bring women together), and providing safe and sustained support for healing, are necessary steps to engage with and meet the needs of communities.
Having a voice means that people “feel that they have some way to participate meaningfully in decisions that are being made about their lives…[that] they have access, points of influence, and conversation,” explained John Paul Lederach, professor of international peacebuilding at the University of Notre Dame.
Key to listening to the voices of the local community is acknowledging them as first responders. “An involvement and control of the relief and rehabilitation process empowers communities,” wrote Arif Hasan, founder and chairperson of the Urban Resource Centre in Karachi, Pakistan. “It improves their relationship with each other, makes it more equitable with state organizations, and highlights aspects of injustice and deprivation that have been invisible.”
Technology is playing a growing role in giving local communities voice and helping relief workers to identify those centers of gravity. “Whether in conflict or even post-conflict reconstruction, technology gives us a possibility of having a collective history but also collective memory,” noted Philip Thigo, a program associate at Social Development Network in Nairobi. “I spoke in a conference where communities were able to map what was important for them and bring it to the public domain: This is who we are and what we are saying, therefore you, the government, have to interact with us within this space. In that sense technology begins to enable communities to say we exist.”
Connecting to Community Points of Power
At the same time, new technology isn’t paramount to connecting with a community, and just having the technology is not sufficient. Leonard Doyle, country spokesperson for the International Organization for Migration (IOM), shared the story of a simple but effective effort to encourage a national conversation in Haiti by enabling “a flow of information between affected communities, humanitarian actors, and local service providers.”
IOM set up more than 140 information booths, complete with suggestion boxes, among the 1,300 camps where more than 1.5 million homeless people were housed after the 2010 earthquake. There was some doubt that the suggestion boxes would attract letters in a country with just a 50 percent literacy rate, but it didn’t take long for the letterboxes to fill up. In just three days, 900 letters were dropped into a booth in one of the poorest communities, Cité Soleil.
“Amid the flotsam of emails and text messages that dominate modern life,” wrote Doyle, “these poignant letters had an authenticity that is hard to ignore….Urgent cases received a quick response; others became part of a ‘crowd-voicing’ effort to listen to those who had been displaced by the earthquake.”
In the end, “the problem is when we NGOs [or other outside bodies] try to create new systems,” observed Thigo. “We do not look at what exists in the community as knowledge. We do not see how to plug our formal thinking into a structure that we may not understand but that we could perhaps simply try to enhance, to provide better services. We think power doesn’t exist in those communities. But there’s a structure of power. It could be leadership that is not necessarily within the formal context that we understand. The fundamental point is: How can we, even during disasters, connect to these points of power?”
Download After the Disaster: Rebuilding Communities from the Wilson Center. -
From the Wilson Center:
Addressing Gender-Based Violence Across Humanitarian Development in Haiti
›By Theresa Polk // Monday, December 5, 2011Women and girls living in displacement camps in post-earthquake Haiti are “the most vulnerable of a very vulnerable population,” according to Amanda Klasing, women’s rights researcher at Human Rights Watch. Klasing was joined by Leora Ward, technical advisor for women’s protection and empowerment at International Rescue Committee (IRC), and Emily Jacobi, executive director of Digital Democracy, for a November 15 panel discussion at the Wilson Center on gender-based violence in Haiti. “Unless we address the violence – the actual experience of violence that women and girls continue to experience at very high rates in Haiti – we [aren’t] going to be able to create a general environment for women and girls to participate in the rebuilding of their country,” Ward said.
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Women More Vulnerable After Natural Disasters
“There is a history and a context for sexual violence in Haiti,” Klasing said. “The earthquake didn’t happen in a bubble.” A study published in The Lancet found that approximately 35,000 women in the Port-au-Prince metropolitan area were victims of sexual assault in the 22 months following the 2004 departure of President Aristide. According to Klasing, sexual violence was historically widely used as a tool for political repression in Haiti, including by security forces during the 1991-94 military regime and under dictator “Baby Doc” Jean-Claude Duvalier.
During and in the aftermath of natural disasters, IRC has found that women are more likely to die than men; are at increased risk of violence; are more vulnerable to lapses in access to health care; and will experience ongoing economic vulnerability, said Ward. “Disasters break down social networks and systems that help protect women and girls,” she said.
While the data on the rate of gender-based violence after Haiti’s earthquake is lacking, “individual vulnerability for gender-based violence has increased, and so the concern, and the response, should reflect that,” Klasing said.
Unfortunately, humanitarian workers rarely undertake measures to respond to sexual violence at the beginning, according to Ward. “Crucial protection systems and response services are typically implemented long after the initial days of the crisis,” she said. “The humanitarian community typically prioritizes food aid, healthcare, water and sanitation services, and shelter from the onset of a response to a natural disaster, often preferring to wait until later to address the issue of sexual violence in an emergency.”
Using Technology To Amplify Women’s Voices
Digital Democracy was formed in 2008 to use technology to enhance civic participation and democratic engagement. The staff already in Port-au-Prince when the earthquake struck became very involved in the technology community’s immediate response, said Jacobi. “Our focus…led us to start working with women specifically, because we felt like they were being just further marginalized and made vulnerable by the disaster relief process,” she said.
Sixty-seven percent of the women in the displacement camps have mobile phones, said Jacobi. Even without access to electricity and other basic needs, women were finding ways to charge their phones and to use those tools to communicate after the disaster, she said.
Digital Democracy helped Haitian NGO KOFAVIV (the Commission of Women Victims for Victims) to incorporate technology into their efforts to provide services and support to victims of sexual violence. They used free, open-source software, such as Frontline SMS and Ushahidi, to facilitate communication and track incidents of gender-based violence. In August, they launched a call center where women can report rapes, access information, and find services.
“The idea of a helpline isn’t very innovative,” Jacobi said, but in Haiti, services like 911 or crisis helplines did not exist. “It is innovative for this group of women to choose to put their resources, and their time, and their energy to trying to reach beyond their current network…to try and reach actually a much wider network in a way technology can do better, than simply sending out women to every single camp.”
Long-Term Funding, Focus on Women Needed
However, despite renewed attention to Haiti, the sustained success of these programs is in question. “Long-term funding for prevention and service provision is a problem–a huge problem–and we are talking about an issue that cannot be resolved in one year, in two years,” said Ward. “Again, [sexual violence] existed before the earthquake, and it has even gotten worse. And funding, I think, cannot be ignored as a critical piece.”
“The perspective of women has not necessarily been taken into account in post-earthquake Haiti, either in the recovery, or in the reconstruction,” added Klasing. “I think that is a challenge for the international community – how are we going to get these women and girls into the process?”
Nevertheless, although the rate of gender-based violence isn’t necessarily decreasing yet, “we are seeing a real building up of resistance networks, and networks of men and women working to combat these challenges,” said Jacobi.
Event ResourcesImage credit: Survivors Connect. -
UNiTE To End Violence Against Women
›By Schuyler Null // Friday, November 25, 2011Today is the International Day to End Violence Against Women, an awareness and advocacy campaign organized by a host of UN agencies and offices “to galvanize action across the UN system to prevent and punish violence against women.”
Gender equity and inequity play a role in a myriad of international development, health, security, and even environmental issues, from rape as a weapon of war; demography’s effects on political stability; maternal health and its impact on child development; women’s rights as a social stability issue; and the disproportionate effect of climate change on rural women.MORE
The numbers around gender-based violence are staggering. According to the UN:
Here are some of New Security Beat’s posts on gender-based violence and inequity and their intersection with development, the environment, and security:- 70 percent of women experience physical or sexual violence from men in their lifetime.
- Approximately 250,000 to 500,000 women and girls were raped in the 1994 Rwandan genocide, and in the eastern Democratic Republic of Congo (DRC), at least 200,000 cases of sexual violence, mostly involving women and girls, have been documented since 1996, though the actual numbers are considered to be much higher.
- In the United States, one-third of women murdered each year are killed by intimate partners; in South Africa, a woman is killed every six hours by an intimate partner; in India, 22 women were killed each day in dowry-related murders in 2007; and in Guatemala, two women are murdered, on average, each day.
- Over 60 million girls worldwide are child brides, married before the age of 18, primarily in South Asia (31.1 million) and sub-Saharan Africa (14.1 million).
Gender-Based Violence in the DRC: Research Findings and Programmatic Implications:
Dr. Lynn Lawry, senior health stability and humanitarian assistance specialist at the U.S. Department of Defense, presented findings from the first cross-sectional, randomized cluster study on gender-based violence in the DRC at the Wilson Center this year. The first of its kind in the region, the population-based, quantitative study covered three districts in the DRC and a total of 5.2 million adults, comprehensively assessing gender-based violence, including its prevalence, circumstances, perpetrators, and physical and mental health impacts.
Pop Audio: Judith Bruce on Empowering Adolescent Girls in Post-Earthquake Haiti: “The most striking thing about post-conflict and post-disaster environments is that what lurks there is also this extraordinary opportunity,” said Judith Bruce, a senior associate and policy analyst with the Population Council. Bruce spent time last year working with the Haiti Adolescent Girls Network, a coalition of humanitarian groups conducting workshops focused on the educational, health, and security needs of the country’s vulnerable female youth population.
The Walk to Water in Conflict-Affected Areas: Constituting a majority of the world’s poor and at the same time bearing responsibility for half the world’s food production and most family health and nutrition needs, women and girls regularly bear the burden of procuring water for multiple household and agricultural uses. When water is not readily accessible, they become a highly vulnerable group. Where access to water is limited, the walk to water is too often accompanied by the threat of attack and violence.
Weathering Change: New Film Links Climate Adaptation and Family Planning: “Our planet is changing. Our population is growing. Each one of us is impacting the environment…but not equally. Each one of us will be affected…but not equally,” asserts the new documentary, Weathering Change, launched at the Wilson Center in September. The film, produced by Population Action International, explores the devastating impacts of climate change on the lives of women in developing countries through personal stories from Ethiopia, Nepal, and Peru.
Sajeda Amin on Population Growth, Urbanization, and Gender Rights in Bangladesh:
The Population Council’s Sajeda Amin describes the Growing Up Safe and Healthy (SAFE) project, launched in Dhaka and other Bangladeshi cities last. The initiative aims, to increase access to reproductive healthcare services for adolescent girls and young women, bolstering social services to protect those populations from (and offer treatment for) gender-based violence, and strengthen laws designed to reduce the prevalence of child marriage – a long-standing Bangladeshi institution that keeps population growth rates high while denying many young women the opportunity to pursue economic and educational advancement.
No Peace Without Women: On October 31, 2000, the UN Security Council adopted Resolution 1325, which called for women’s equal participation in all efforts to maintain and promote peace and security; however, little progress has been made over these last 10 years and women remain on the periphery when it comes to post-conflict reconstruction and development. A report from the humanitarian organization CARE concedes that “much of the action remains declarative rather than operational.”
Addressing Gender-Based Violence to Curb HIV: At last year’s International AIDS Conference in Vienna an astonishing development in the campaign to stem the spread of HIV/AIDS was unveiled – a microbicide with the ability to reduce the risk of transmission of HIV. This welcome development coincides with an intensified focus on women’s health and security needs among donors, especially the United States.
The Future of Women in the MENA Region: A Tunisian and Egyptian Perspective: Lilia Labidi, minister of women’s affairs for the Republic of Tunisia and former Wilson Center fellow, joined Moushira Khattab, former minister of family and population for Egypt, this summer at the Wilson Center to discuss the role and expectations of women in the Egyptian and Tunisian revolutions, as well as issues to consider as these two countries move forward.
Sources: UN Secretary-General’s Office. -
Eye On:
Failed States Index 2011
›By Kellie Furr // Wednesday, July 20, 2011“The reasons for state weakness and failure are complex, but not unpredictable,” said J.J. Messner, one of the founders of the Fund for Peace’s Failed States Index, at the launch of the 2011 version of report in Washington last month. The Index is an analytical tool that could aid policymakers and governments seeking to prevent and mitigate state collapse by identifying patterns of underlying drivers of state instability.
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The Index ranks 177 countries according to 12 primary social, economic, and political indicators based on analysis of “thousands of news and information sources and millions of documents” and distilled into a form that is meant to be “relevant as well as easily digestible and informative,” according to the creators. “By highlighting pertinent issues in weak and failing states,” they write, the Index “makes political risk assessment and early warning of conflict accessible to policymakers and the public at large.”
Common Threats: Demographic and Natural Resource Pressures
The Index reveals that half of the 10-most fragile states are acutely demographically challenged. The composite “Demographic Pressures” category takes into account population density, growth, and distribution; land and resource competition; water scarcity; food security; the impact of natural disasters; and public health prevention and control. Additional population indices are found in “Massive Movement of Refugees or Internally Displaced Persons (IDPs),” and health indicators, including infant mortality, water, and sanitation, are spread across several categories.
Not surprisingly, some of the most conflict-ridden countries show up at the top of the list. The Index highlights some of the lesser known issues that contribute to their misery: demographic and natural resource stresses in Afghanistan, Iraq, Nigeria, Pakistan, and Yemen (a list that would include Palestine, if inclusion in the Index were not contingent on UN membership); the DRC’s conflict minerals; and Somalia and Sudan’s myriad of environmental and migration problems, which play major roles in their continued instability.
Haiti, with its poor health and lack of infrastructure and disaster resilience, was deemed the Index’s “most-worsened” state of 2011. The January 2010 earthquake and its ensuing “chaos and humanitarian catastrophe” demonstrated that a single event can trigger the collapse of virtually every other sector of society, causing what Messner termed the “Humpty Dumpty effect” – while a state can deteriorate quickly, it is much harder to put it back together again.
The inclusion of natural resource governance within the social and economic indicators would render the Index a more complete analytical tool. In a 2009 report, the UN Environment Program (UNEP) found that “since 1990, at least eighteen violent conflicts have been fueled by the exploitation of natural resources,” and that effective natural resource management is a necessary component of conflict prevention and peacebuilding operations.
The Elephant in the Room: Predicting the Arab Spring
Why did the Index fail to predict the Arab Spring sweeping the Middle East and North Africa? Many critics assert that the inconsistent ranking of the states, ranging from Yemen (ranked 13th) to Bahrain (ranked 129th), demonstrates that the Index is a poor indicator of state instability. Particularly, critics argue that many of the countries experiencing revolutions were ranked artificially low.
“Of course, the Failed States Index did not predict the Arab Spring, and nor is it intended to predict such upheavals,” said Messner at the launch event. “But by digging down deeper into the specific indicator analysis, it was possible to observe the growing tensions in those countries.” The Index has consistently highlighted specific troubling indicators for the region, such as severe demographic pressures, migration, group grievance, human rights, state legitimacy, and political elitism.
Blake Hounshell, a correspondent with Foreign Policy (long-time collaborators with the Fund for Peace on the Index), wrote that the Index was never meant to be a “crystal ball” – even the best statistical data cannot truly encapsulate the complex realities that lead to inherently unpredictable events, such as revolutions. “It’s thousands of individual decisions, not rows of statistics, that add up to political upheaval,” Hounshell continued.
Demographer Richard Cincotta’s work on Tunisia’s revolution illuminates how the Index’s linear indicators can mask a complex reality. Whereas the Failed States Index simply measures “demographic pressure” as a linear function of how youthful a population is, Cincotta pointed out at a Wilson Center event that it was actually Tunisia’s relative demographic maturity that paved the way for its revolution and gives it a good chance of achieving a liberal democracy. Other countries in the region are much younger than Tunisia (Yemen being the youngest). The Arab Spring demonstrates that static indicators alone often do not have the capacity to predict complex social and political revolutions.
Sources: Foreign Policy, The Fund for Peace, UNEP.
Image Credit: Failed States Index 2011, Foreign Policy. -
From the Wilson Center:
Preparing for the Impact of a Changing Climate on U.S. Humanitarian and Disaster Response
›By Kellie Furr // Wednesday, July 13, 2011Climate-related disasters could significantly impact military and civilian humanitarian response systems, so “an ounce of prevention now is worth a pound of cure in the future,” said CNA analyst E.D. McGrady at the Wilson Center launch of An Ounce of Preparation: Preparing for the Impact of a Changing Climate on U.S. Humanitarian and Disaster Response. The report, jointly published by CNA and Oxfam America, examines how climate change could affect the risk of natural disasters and U.S. government’s response to humanitarian emergencies. [Video Below]
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Connecting the Dots Between Climate Change, Disaster Relief, and Security
The frequency of – and costs associated with – natural disasters are rising in part due to climate change, said McGrady, particularly for complex emergencies with underlying social, economic, or political problems, an overwhelming percentage of which occur in the developing world. In addition to the prospect of more intense storms and changing weather patterns, “economic and social stresses from agricultural disruption and [human] migration” will place an additional burden on already marginalized communities, he said.
Paul O’Brien, vice president for policy and campaigns at Oxfam America said the humanitarian assistance community needs to galvanize the American public and help them “connect the dots” between climate change, disaster relief, and security.
As a “threat multiplier,” climate change will likely exacerbate existing threats to natural and human systems, such as water scarcity, food insecurity, and global health deterioration, said Vice Admiral Lee Gunn, USN (ret.), president of CNA’s Institute for Public Research. Major General Richard Engel, USAF (ret.), of the National Intelligence Council identified shifting disease patterns and infrastructural damage as other potential security threats that could be exacerbated by climate change.
“We must fight disease, fight hunger, and help people overcome the environments which they face,” said Gunn. “Desperation and hopelessness are…the breeding ground for fanaticism.”
U.S. Response: Civilian and Military Efforts
The United States plays a very significant role in global humanitarian assistance, “typically providing 40 to 50 percent of resources in a given year,” said Marc Cohen, senior researcher on humanitarian policy and climate change at Oxfam America.
The civilian sector provides the majority of U.S. humanitarian assistance, said Cohen, including the USAID Office of Foreign Disaster Assistance (OFDA) and the State Department’s Bureau of Population, Refugees, and Migration. These organizations provide leadership, funding, and food aid to developing countries in times of crisis, but also beforehand: “The internal rationale [of the Office of Foreign Disaster Assistance] is to reduce risk and increase the resilience of people to reduce the need for humanitarian assistance in the future,” said Edward Carr, climate change coordinator at USAID’s Bureau for Democracy, Conflict, and Humanitarian Assistance.
The U.S. military complements and strengthens civilian humanitarian assistance efforts by accessing areas that civilian teams cannot reach. The military can utilize its heavy lift capability, in-theater logistics, and command and control functions when transportation and communications infrastructures are impaired, said McGrady, and if the situation calls for it, they can also provide security. In addition, the military could share lessons learned from its considerable experience planning for complex, unanticipated contingencies with civilian agencies preparing for natural disasters.
“Forgotten Emergencies”
Already under enormous stress, humanitarian assistance and disaster response systems have persistent weaknesses, such as shortfalls in the amount and structure of funding, poor coordination, and lack of political gravitas, said Cohen.
Food-related aid is over-emphasized, said Cohen: “If we break down the shortfalls, we see that appeals for food aid get a better response than the type of response that would build assets and resilience…such as agricultural bolstering and public health measures.” Food aid often does not draw on local resources in developing countries, he said, which does little to improve long-term resilience.
“Assistance is not always based on need…but on short-term political considerations,” said Cohen, asserting that too much aid is supplied to areas such as Afghanistan and Iraq, while “forgotten emergencies,” such as the Niger food crisis, receive far too little. Furthermore, aid distribution needs to be carried out more carefully at the local scale as well: During complex emergencies in fragile states, any perception of unequal assistance has the potential to create “blowback” if the United States is identified with only one side of a conflict.
Engel added that many of the problems associated with humanitarian assistance will be further compounded by increasing urbanization, which concentrates people in areas that do not have adequate or resilient infrastructure for agriculture, water, or energy.
Preparing for Unknown Unknowns
A “whole of government approach” that utilizes the strengths of both the military and civilian humanitarian sectors is necessary to ensure that the United States is prepared for the future effects of climate change on complex emergencies in developing countries, said Engel.
In order to “cut long-term costs and avoid some of the worst outcomes,” the report recommends that the United States:
Cohen singled out “structural budget issues” that pit appropriations for protracted emergencies in places like Iraq, Afghanistan, and Darfur against unanticipated emergencies, like the 2010 earthquake in Haiti. Disaster-risk reduction investments are not a “budgetary trick” to repackage disaster appropriations but a practical way to make more efficient use of current resources, he said: “Studies show that the return on disaster-risk reduction is about seven to one – a pretty good cost-benefit ratio.”- Increase the efficiency of aid delivery by changing the budgetary process;
- Reduce the demand by increasing the resilience of marginal (or close-to-marginal) societies now;
- Be given the legal authority to purchase food aid from local producers in developing countries to bolster delivery efficiency, support economic development, and build agricultural resilience;
- Establish OFDA as the single lead federal agency for disaster preparedness and response, in practice as well as theory;
- Hold an OFDA-led biannual humanitarian planning exercise that is focused in addressing key drivers of climate-related emergencies; and,
- Develop a policy framework on military involvement in humanitarian response.
Edward Carr said that OFDA is already integrating disaster-risk reduction into its other strengths, such as early warning systems, conflict management and mitigation, democracy and governance, and food aid. However, to build truly effective resilience, these efforts must be tied to larger issues, such as economic development and general climate adaptation, he said.
“What worries me most are not actually the things I do know, but the things we cannot predict right now,” said Carr. “These are the biggest challenges we face.”
“Pakistan Floods: thousands of houses destroyed, roads are submerged,” courtesy of flickr user Oxfam International. -
Dot-Mom:
Quality and Quanitity: The State of the World’s Midwifery in 2011
›By Ramona Godbole // Thursday, June 30, 2011Each year, 350,000 women die while pregnant or giving birth, as many as two million newborns die within the first 24 hours of life, and there are 2.6 million stillbirths. Sadly, the majority of these deaths could be prevented if poor and marginalized women in developing countries had access to adequate health facilities and qualified health professionals. In fact, according to the new UNFPA report, State of the World’s Midwifery 2011: Delivering Health, Saving Lives, just doubling the current number of midwives in the 58 countries highlighted in the report could avert 21 percent of maternal, fetal, and newborn deaths.Launched last week, the report is the first of its kind, using new data from 58 low-income countries with high burdens of maternal and neonatal mortality to highlight the challenges and opportunities for developing an effective midwifery workforce.MORE
“Developing quality midwifery services should be an essential component of all strategies aimed at improving maternal and newborn health,” write the authors of the report. Qualified midwives ensure a continuum of essential care throughout pregnancy and birth, and midwives can help facilitate referrals of mothers and newborns to hospitals or specialists when needed:Unless an additional 112,000 midwives are trained, deployed, and retained in supportive environments, 38 of 58 countries surveyed might not met their target to achieve 95 per cent coverage of births by skilled attendants by 2015, as required by Millennium Development Goal 5.
There is a total shortage of 350,000 skilled midwives globally, with some countries, like Chad and Haiti, needing a tenfold increase to match demand, according to the report. But quantity isn’t the only issue; there has also been an insufficient focus on quality of care. Additionally, most countries do not have the capacity to accurately measure the number of practicing midwives, and national policies focusing on maternal and newborn health services often do not view midwifery services as a priority.
To help overcome these challenges, the report outlines a number of “bold steps” to be taken by governments, regulatory bodies, schools, professional associations, NGOs, and donor agencies in order to maximize the impact of investments, improve mutual accountability, and strengthen the midwifery workforce and services. Of course, the needs of each country are unique, and the report ends with individual country profiles that highlight country-specific maternal and neonatal health indicators.
While this report does much to highlight the critical importance of midwives in promoting the health and survival of mothers and newborns, real impact will only come when governments, communities, civil society, and development partners work together to implement these recommendations.
Sources: UNFPA.
Video Credit: UNFPA. -
Reading Radar:
Health Development: Providing Free Care and Overcoming Gender-Based Violence
›By Kellie Furr // Wednesday, June 1, 2011In The Lancet’s “How Did Sierra Leone Provide Free Health Care?,” author John Donnelly of the Ministerial Leadership Initiative attributes the unanticipated success of a free health care program for women and children in Sierra Leone to good organization, transparency, and a high degree of cooperation between the government, donors, and development partners. One distinctive factor that has contributed to the health system’s turnaround is the unusually high level of political will on the part of President Ernest Bai Koroma, writes Donnelly. Similar to Egypt’s health and population initiatives, Sierra Leone’s marked commitment, accountability, and investment as a host country has contributed highly to the success of its program and triggered further investment from donors.
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In “Systematic Violence: A Barrier to Achieving the Millennium Development Goals for Women,” from the Journal of Women’s Health, authors Joia S. Mukherjee, Donna J. Barry, Hind Satti, Maxi Raymonville, Sarah Marsh, and Mary Kay Smith-Fawzi assert that the elevation of women is integral to the achievement of the Millennium Development Goals, to which structural violence serves as a significant barrier. Murkherjee et al. recommend community-based programs to combat structural violence and prevent disease, such as the Partners in Health (PIH) program in Haiti. PIH trains community health workers, expands health care as a public good, and bolsters social determinants, which include increasing access to family planning and education, providing compensation for medical workers, and improving health infrastructure. -
From the Wilson Center:
Reporting on Global Health: A Conversation With the International Reporting Project Fellows
›By Christina Daggett // Tuesday, May 10, 2011“The story is the story, the information is the information, but you can frame it in very different ways,” said freelance journalist Annie Murphy at a roundtable discussion on the current state of global health reporting. Fresh off their five-week assignments, Murphy and three other fellows from the International Reporting Project (IRP) – Jenny Asarnow, Jill Braden Balderas, and Ann S. Kim – spoke at an event at the Woodrow Wilson Center on April 28 about their experiences researching underreported health issues in Haiti, Botswana, Mozambique, and Uganda. [Video Below]
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Taking the Temperature of Global Health Reporting
Global health reporting, like many other forms of journalism, has felt the pinch from the global financial crisis, said Balderas, who edited a recent Kaiser Foundation report on the issue, “Taking the Temperature: The Future of Global Health Journalism.” Other challenges that have led to less global health coverage in mainstream media include an increased focus on “hyper-local” news; “story fatigue” from years of HIV/AIDS coverage; greater focus on epidemics and disasters; and the increasing number of advocacy groups starting their own news services.
Placing global health stories is a big challenge, agreed all four panelists. Who will want to run the story? What form – radio, documentary, print, online – will the story take? According to Murphy, some creative thinking may be needed: “It is global health, but that doesn’t mean we always have to frame it in this box of global health. It will be global health no matter what we do, so I think it’s also important for us to feed it into other events and issues that are important.”
(Re)building Maternal Healthcare in Haiti
With the worst maternal and infant mortality rates in the Western Hemisphere, Haiti needs medical providers of all kinds, said Asarnow, but especially skilled birth attendants. The devastating earthquake in 2010 destroyed Haiti’s only midwifery school, located in Port-au-Prince, killing many students and instructors. The school is still struggling to graduate a class of 15 people, she said.
In the rural town of Hinche, located in Haiti’s Central Plateau region, Asarnow frequently visited a public hospital that provided pregnant women with free obstetric care. Yet, she said, “even with free care, there [were] still a lot of barriers for women coming to the hospital to get care.” For example, the family members of expectant mothers had to provide sheets, clothing, food, and a bucket for personal needs. In addition, some women were too poor to afford transportation to and from the hospital.
Most women in Haiti, though, give birth at home with the help of traditional birth attendants, called matrones, Asarnow said. These matrones, popular in rural areas, are not formally educated in midwifery, but the government, along with non-profits such as Midwives for Haiti, have provided the matrones with training in basic health care and emergency situations.
Simply reporting on childbirth turned out to be a challenge, said Asarnow. “It’s hard to get people interested in something that just happens to most women,” she said; other more unusual health problems, such as infectious diseases, tend to garner more interest.
Finding Health Sovereignty in Mozambique
Health sovereignty, explained Murphy, is “the idea that nations have the right to make decisions about health and about how people are going to be treated” – an issue that is particularly pointed in Mozambique, where 50 percent of the national budget and 70 percent of the annual health budget is tied to international aid.
Mozambique, said Murphy, has only 1,000 doctors to serve a population of 22 million. By contrast, the country has an estimated 50,000 traditional healers. As a result, she said, most Mozambicans use traditional healing for at least part of their regular health care.
While researching traditional healers in the northern province of Tete, Murphy investigated a large Brazilian-owned coal mine that had displaced 5,000 local people when it was built. Mining is a major economic activity in Mozambique, yet mining companies are taxed a mere three percent by the government, said Murphy.
Health reporting doesn’t have to only cover traditional health issues, said Murphy. “The environment, natural resources, and how a country earns its money very much have to do with the health of the people who are living there,” she said. “How can you talk about being sovereign and providing health to your citizens if you don’t have the money to do that?”
Treating the Over-Treatment of Malaria in Uganda
“Malaria is quite over-treated” in Uganda, said Balderas. There’s the “idea that if you have a fever, you have malaria.” Consequently, the rate of misdiagnosis can reach alarming rates in some areas, she said.
Balderas said an estimated 50 percent of Ugandans get free treatment through the public sector. However, only donor-funded facilities are equipped with the rapid diagnosis test (or RDT), which takes only 20 minutes to determine the presence of malaria in a blood sample, she said. If these facilities were more widespread, misdiagnoses rates could easily be lowered.
Other challenges to the accurate diagnosis and treatment of malaria include faulty equipment, shortages of electricity and lab technicians, human error, corruption, bureaucratic entanglements, and presumptive diagnoses. For example, sometimes health workers do not know what is causing a patient’s fever, Balderas said, but they prescribe malaria treatments anyway because “they want to be able to give someone a treatment; they want to feel like they’re helping people.”
“There are certainly a ton of issues that relate to health,” Balderas said, such as poverty and corruption. Everyone she interviewed in Uganda – with the exception of government officials – identified the corruption in the country’s drug sector as a key problem.
Helping “Africa” One Small Story at a Time
Inspired by a World Health Organization study, which found “at least a 60 percent reduction in HIV infection among men who were circumcised,” Kim went to Botswana to investigate infant circumcision, a practice that is gaining popularity but is still alien. “I would meet people in the course of my day and they would ask me what I was doing there and I would talk about circumcision. They’d say, ‘Oh, I really want to get my baby circumcised. How do I do that?’” she reported.
The most powerful moment of her trip, said Kim, came when she was researching cervical cancer – the number one cancer among women in Botswana. As she waited with a woman to receive her lab results, Kim asked her if she was nervous. The woman, who was HIV-positive, said, “Yeah, I’m really worried. To me, it would be worse to get cervical cancer than to have HIV.” Even though Botswana is a middle-income country, said Kim, there are far more resources available to treat HIV than cancer.
Kim said that when presenting her work it was important for her to bring in the human element and not just the statistics: “I hope that, in whatever small way, even these small stories will help get issues in various countries on the map, especially in Africa where we tend to think of it as ‘Africa’ and not so much as different countries with different personalities and different situations.”
Sources: Malaria Journal, UNFPA, World Health Organization.
Image Credit: David Hawxhurst/Woodrow Wilson Center. -
From the Wilson Center:
The U.S. Government’s Response to Disasters: Myth, Mistakes, and Recovery
›By Ramona Godbole // Thursday, April 28, 2011“Major crises and disasters have massively changed over the last generation,” said Dr. Frederick Burkle, senior public policy scholar at the Woodrow Wilson Center and senior fellow and scientist at the Harvard Humanitarian Initiative. “We have to start a new narrative of what we need to do to address [them].”
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To discuss the emerging and persistent challenges of disaster prevention, preparedness, response, and recovery, Burkle was joined by Paul Born, co-founder and director of the Tamarack Institute for Community Engagement; Leonard Doyle, Haiti country spokesperson at the International Organization for Migration; Arif Hasan, adviser at the Orangi Pilot Project and founder and chairman at the Urban Resource Centre; and Dr. Eliane Ubalijoro, adjunct professor at McGill University and member of the Presidential Advisory Council for Rwandan President Paul Kagame.
“Retrieving the Wisdom of Those in Need”
Unfortunately, disaster responses often fail to “listen and gain a corner on the obvious,” said Born, discussing the need for community engagement and healing in times of disaster and conflict.
After Hurricane Katrina, for example, the formal disaster response failed to use hundreds of available buses to evacuate people, leaving thousands of people stranded in the floods. “If people were engaged, had a role to play, knew what to do, were part of a team, would this have made a difference? Would those buses have been deployed to help people?” asked Born.
Effective disaster response must utilize “the assets, the skills, and the knowledge that are present,” concluded Born. For example, when the systems in place by the Philippine government in the village of Talba failed to give proper warning to evacuate from a volcanic eruption, “it was a parallel warning system, developed by the community, that warned people, on time, to vacate the area and avoid any loss of life,” said Born. Community preparedness and engagement led to better utilization of available humanitarian assets and mitigated what could have been a much more severe disaster.
The Changing Nature of Humanitarian Emergencies
Increasingly, humanitarian crises are the result of unconventional warfare, causing major challenges for the humanitarian community, said Burkle. Rather than refugees, “what we are beginning to see today is an unprecedented number of internally displaced people.”
Many of the displaced migrate to urban settings, contributing to rapid urbanization which is straining water, sanitation, and public health infrastructure. In these settings, he said, there is sometimes only one latrine for every 200 people, new and infectious diseases are rampant, and high rates of violence and rape are common, putting women particularly at risk.
“It is a lot more than population size – it’s really density of population,” said Burkle. In Mumbai, for example, there is an average of 30,000 people per square kilometer, but there are major areas of the city with over one million people per square kilometer.
“People moving to the cities are still remaining in extreme poverty,” said Burkle. While the majority of the poor once lived in low-income fragile states, recent population data indicates that 72 percent of the world’s poor now live in middle income countries like India, Indonesia, and China. “It’s a total reversal – we’ve spent almost 20 years crafting our foreign aid budgets and policy around this…we have to start a new narrative about what we are going to do.”
“The other issue that I don’t think we hear about, but certainly the young people in the audience will be dealing with on a daily basis, are the biodiversity crises,” said Burkle. “Of the 34 biodiverse areas, 23 have experienced prolonged conflict,” which has had major impacts on the availability of water, food, and energy in these regions, said Burkle.
Moving forward, “we have to change the humanitarian community; we have to have more accountability and more accreditation, leading to a blueprint for professionalizing the humanitarian field,” concluded Burkle.
Community and Communication in Haiti
A little over one year after the devastating earthquake in Haiti, 680,000 people remain internally displaced, said Doyle. “About half the population has moved out of the camps, and there is some congratulations to be given to the humanitarian community for organizing that,” he said. “But, when you look at the statistics…only a tiny fraction of these people have reached what you would call durable solutions such as sustainable housing.”
“There is clearly a problem… why has more progress not taken place given the number of international organizations there and the generosity of the funding?” asked Doyle.
“People have a right to communicate and there is a benefit in that communication,” said Doyle. To help make this possible in the Haitian displacement camps, he and his colleagues at the International Organization of Migration (IOM) set up 140 suggestion boxes. The response was amazing, he said, and with the help of a local Haitian organization, IOM has begun broadcasting some of the over 5,000 letters received on a daily radio show.
“We need to help create respectful conversations in countries where we do so much hard work but see so much of it go nowhere,” said Doyle. Information from the letters has been compiled into reports detailing the major challenges faced by people including a lack of jobs, education, and housing. These letters are being used as a monitoring and accountability mechanism through which Haitians can tell NGOs and donors the successes and failures of projects being implemented in their communities. “Through this communication you can see what the community needs, rather than what the experts tell you the community needs,” he said.
Engaging Local Communities
“Regions are sometimes so badly devastated [after a disaster], that to rehabilitate their agriculture, transport, water supply systems, is a very daunting task,” said Hasan. His home country of Pakistan faced all of these challenges after heavy rains and subsequent flooding wiped out 3,000 villages and affected over 20 million people last year.
“Without a governance system, you cannot provide rehabilitation or relief,” Hasan said, citing an added challenge for disaster response in many developing countries. Often the needs of the people are not translated in to policy actions, he said, and “there is a big difference between what people want and what politicians want.”
Hasan offered some insights on how the development community can work with local communities to improve disaster response, pointing out that “pre-disaster situations determine the effectiveness of relief and rehabilitation.” Existing mechanisms to provide development assistance can be used to efficiently deliver goods and services in emergencies, he said. By fostering “true partnerships” international NGOs can help communities and governments should manage reconstruction and relief efforts after disasters using local materials, labor, and technologies, he said. Engaging communities in reconstruction “can be a really important healing process.”
Recovery and Resilience
“When you have a community that has been reduced to ashes, how can you retrieve hope so that transformation can happen?” asked Ubalijoro, stressing the importance of building community resilience after disasters. “We’ve been talking about disasters, but it’s important to remember how we learn to dream again together.”
Baskets of Hope is a project that aims to help Rwandan women recover from the genocide by providing training and jobs weaving baskets that are sold internationally. In addition to providing a source of income, the project also provides information about health and nutrition. With this multi-pronged approach, Baskets of Hope helps families to recover and move forward. “There’s an interesting relationship between weaving these baskets that are allowing these women to have economic empowerment and what it requires after a time of trauma to reweave the fabric of society,” said Ubalijoro.
Youth who have survived man-made or natural disasters are particularly vulnerable, said Ubalijoro. She and her colleagues work to link Rwandan youth with Holocaust survivors so that they can share their memories, pictures, and stories with one another. “Retrieving the wisdom from those who have gone through the unimaginable and having them share their experiences shows youth that even though they’ve lost everything, there are ways to move forward.”
Sources: Conservation International, Institute of Development Studies, International Organization for Migration, USAID.
Photo Credit: “Pakistan Floods” courtesy of flickr user IRIN Photos. -
Watch: Frederick Burkle on Lessons from Haiti and Professionalizing Humanitarian Assistance
›By Schuyler Null // Wednesday, April 20, 2011“Haiti – in terms of coordination – was a debacle,” said Frederick Burkle, senior fellow with the Harvard Humanitarian Initiative and a visiting scientist at the Harvard School of Public Health. Burkle, who is also a senior public policy scholar at the Wilson Center, said that after the 2010 earthquake, “the large majority of people who showed up were under the age of 30 and this was their first disaster event.”MORE
As a result, “best practices did not necessarily occur,” Burkle said. “Ninety-five percent of the work is probably done by 45 of the major NGOs,” but, he said, the number of “mom-and-pop shows” and other small NGOs in “The Republic of NGOs” is in the thousands.
Non-healthcare providers ended up providing services that they were not trained to provide – even amputations, Burkle said. “We certainly relish the humanitarian spirit of those who show up, but we have to have some coordination to ensure that best practices occur and that it goes in the right direction.”
“The professionalization blueprint really calls for courses, curriculum, and best practice standards,” said Burkle. The Harvard Humanitarian Initiative is working with the UN Office for the Coordination of Humanitarian Affairs, World Health Organization, and others to provide these resources.
“There’s a movement afoot within the humanitarian community itself to finally professionalize the humanitarian profession,” Burkle said, spurred on, in part, by the poorly coordinated responses to events like the Haiti earthquake. -
Eye On:
Mapping the “Republic of NGOs” in Haiti
›By Hannah Marqusee // Monday, January 24, 2011One year after the devastating earthquake that hit Haiti, InterAction has teamed up with the U.S. Chamber of Commerce’s Business Civic Leadership Center and FedEx to launch the Haiti Aid Map, an interactive visual mapping platform of individual aid projects being conducted in Haiti. The goals of the map are to increase aid transparency, facilitate partnerships, and help NGOs and others better coordinate and allocate resources to aid relief and reconstruction efforts.
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With an estimated 10,000 NGOs operating on the ground – the second largest per capita in the world – Haiti has been referred to as “a republic of NGOs.” The Haiti Aid Map is an effort to help the humanitarian community – which has been criticized for lack of accountability, poor transparency, and corruption – better coordinate its response.
The map features 479 projects being operated all over the country by 77 local and international NGOs, most of which are InterAction members. Projects can be browsed by location, sector, or organization and include information on project donors, budgets, timelines, and the number of people reached by the project.While InterAction’s map covers their donors’ response, it leaves out the thousands of government and other NGO projects being conducted in Haiti. USAID recently released a map of U.S. government projects in Haiti (see right) by sector and location.
“The goal is not to rebuild Haiti but to build a different Haiti,” said Sam Worthington, President and CEO of InterAction, speaking exactly one year after the earthquake struck at the map’s formal launch this month. “The relief effort will still be here a year from now.” The goal of the map will be to help coordinate activities as reconstruction continues in the future.
The map is the first part of a larger mapping platform, called the NGO Aid Map, which will include not only the Haiti aid map but also projects working on food security in other developing countries. The food security map is due to be launched in March 2011.
Sources: Clinton Foundation, InterAction, NPR, ReliefWeb, USIP.
Image Credit: Adapted from Haiti Aid Map. -
Haiti 2011: Looking One Year Back and Twenty Years Forward
›Andrew Morton, UNEP
By ECSP Staff // Friday, January 14, 2011This piece first appeared on the website of the Haiti Regeneration Initiative – a new collaborative venture between the UN, the government of Haiti, the Earth Institute at Columbia University, Catholic Relief Services, and a wide range of other implementing partners.
In 2010, Haiti endured a year like no other. The country was struck by a devastating earthquake, a cholera epidemic, floods, violence, and political uncertainty. At the same time, Haiti witnessed heroic rescue and relief efforts and an enormous demonstration of international goodwill. Today, recovery and reconstruction are taking place, albeit at a frustratingly slow pace and not currently at the scale of existing needs.MORE
Just as importantly, 2010 brought a renewed awareness of the need for lasting solutions and improvements in the design and delivery of international aid. During the next few days, we will look back on the tragic events of January 12th, 2010, while at the same time, we must look forward, not just one year, but 20.
A Failed Recovery in a Fragile State
Already before the earthquake, Haiti was a fragile state trapped in a slow but vicious negative spiral. A tightly interconnected trio of chronic environmental, political, and socio-economic crises has gradually ensured that Haiti has had the lowest human development indicators in the Western Hemisphere, with life-long poverty, chronic hunger, and violence. Catastrophic events, such as natural disasters, epidemics, and political violence, have simply steepened the descent. Moreover, disaster recovery efforts to date have systematically failed to bring the country back to pre-disaster levels.
In spite of this depressing analysis and forecast, we should not resign ourselves to failure. The situation can be turned around but only with great effort and by foregoing “business as usual.”
The first step towards change is full recognition of the situation. In the case of Haiti, this means recognizing the marked failure of foreign recovery and development assistance to date. It is pointless to blame any particular institution or individual for this: The current state of Haiti is the culmination of generations of efforts and decisions, good and bad, combined with rapid population growth and an inherent vulnerability to natural hazards. (Editor’s note: according to the UN, Haiti’s fertility rate tripled in the immediate aftermath of the earthquake last year.)
The second step is planning. While relatively solid recovery plans have been developed by the government of Haiti with international assistance, their implementation has not so far met with success, due to four interlinked problems.
First, the humanitarian imperative for urgent and chronic relief is overrunning all good intentions for recovery and development – it is politically impossible, inhumane, and simply unwise to ignore the basic resource needs of a cholera epidemic and a million people living in tents.
Second, nothing suppresses development investments like political violence and uncertainty: Few donors, and even fewer companies, will invest while riots and political uncertainty paralyze the country and destroy its reputation.
Third, the planning process is necessarily democratic and participatory; as a result, however, virtually all of the country’s needs are listed with no reliable process of thematic or geographic prioritization.
Finally – and perhaps most importantly – although the plans are official and uncontested, they generally lack broad credibility and commitment. Weary aid workers, government officials, donors and the general public look back at the fate of previous plans and, not surprisingly, expect these latest efforts to fail just as others have before.
Regenerating Haiti
Unlike virtually all other aid organizations I have met in Haiti, the team behind the Haiti Regeneration Initiative (HRI) has fortunately been given the vital time and seed funding to reflect on these issues and try something really different. After two years of preparation, on January 4, 2010, we launched a long-term rural sustainable development initiative for the southwestern tip of Haiti. The Côte Sud Initiative aims to transform the lives and the degraded environment of 200,000 people living in one of the poorest yet most beautiful parts of Haiti.
This specific initiative will only directly assist two percent of the population of Haiti, but just as importantly, we aim to demonstrate that sustainable development is truly possible in this country. Because national-scale issues require national-scale efforts, we also aim to promote change through dialogue and assisting the government of Haiti to develop and deliver on sustainable development plans that work. This is the primary mission of the HRI.
We must arrest the long-term decline as soon as possible. This includes, but is not limited to, basic recovery from the earthquake. At the same time, we need to establish the foundations for the long-term radical changes that are an absolute prerequisite to achieving sustainable development in Haiti. We must prepare to turn the vicious circles into virtuous ones.
So what are the short- to medium-term priorities?
The first is political stabilization, as vital foreign aid and direct foreign investment will simply not arrive in the face of such negative news and uncertainty.
Second, a massive aid investment in potable water and sanitation is required to suppress cholera in the longer term. No country can develop in the midst of recurrent major epidemics. This investment needs to be designed for sustainability; in other words, infrastructure needs to be accompanied by realistic, locally financed mechanisms for maintenance. Otherwise it will become useless within weeks of installation.
Third, persistence is needed on the current debris clearance and rebuilding efforts; we know from many other countries that such efforts can take years to be completed.
Finally, development aid should move out of Port-au-Prince and into the regions. In 2010, the massive influx of earthquake relief and reconstruction aid actually increased the economic pull of the capital and exacerbated existing urban problems.
What to do to prepare for the long term? Implementing radical change requires political support and even cultural reform, so in addition to good ideas, the HRI partnership will work hard to develop a sense of national ownership of the solutions as well as the problems.
Many of the ideas are not new: mildly decentralized development, diversified and value-added agriculture, niche tourism, improved aid coordination, public-private partnerships, etc.
Many, however, are radical, including a proposed paradigm change on migration and remittances, education, food security and import policies, widespread privatization, harsh revisions and rebuttals of traditional development models and assumptions, and adaptation to the new types of religious NGOs. These are just a few of the concepts and opportunities we have identified and will work to make a reality in Haiti.
Over the next few years, the HRI hopes to foster an intelligent and useful dialogue on sustainable development in Haiti. We look forward to having all of those who are concerned about and interested in helping Haiti join us in the debate.
Andrew Morton is the Haiti Regeneration coordinator and a senior staff member at UNEP. For more information on the Haiti Regeneration Initiative please see www.haitiregeneration.org.
Sources: BBC, Haiti Regeneration Initiative, United Nations Development Programme.
Image Credit: “Rebuilding as a community,” courtesy of flickr user Save the Children. -
Guest Contributor:
The Cholera Quandary
›By Sarah Kornblet // Monday, December 27, 2010
The original version of this article first appeared in the Stimson Center Spotlight series, November 19, 2010.
Cholera is usually seen as one of the most devastating infections of the 19th century. Trade routes carried cholera from India to the great cities of Europe and the United States. Disease, fear, and political unrest spread in great waves that cost millions of lives. After much destruction, it was only with science and resources that certain populations were able to curb the epidemic.One of the most celebrated lessons in the history of public health involves a cholera outbreak in London in 1854 and efforts by John Snow – celebrated as the father of epidemiology – to control it. At the time, it was not clear that cholera was a waterborne bacterial infection that caused severe diarrhea and vomiting, and sometimes fatal dehydration. Snow proved that the outbreaks decimating communities spread from contaminated water. Water and sanitation services had virtually eliminated cholera epidemics in the developed world by the early 1900s.
Today, cholera has been nearly eradicated in the developed world, but continues to be endemic in poorer countries. Risks seem to be rising as larger populations are crowded into unsanitary conditions. The World Health Organization (WHO) estimates three to five million illnesses and 100,000-200,000 deaths from cholera each year. If caught early, infections are treatable with inexpensive oral rehydration solutions. For much of the world, these options are unavailable or underused – the mere presence of cholera serves as an indicator of a country’s socioeconomic status and health system capabilities.
The cholera epidemics that are currently menacing countries on three different continents – Asia, Africa, and North America – raise tough questions about what is required to protect the world’s vulnerable populations. We know how to predict the crisis of cholera, prevent outbreaks, and contain them when they occur. To control cholera, what is needed is not cutting-edge technologies, but will, transparency, and resources – and where cholera appears, at least one of these three factors has failed.
Currently, cholera outbreaks in Pakistan, Haiti, and Nigeria are piling misery upon misery. Cholera in post-flood Pakistan comes as no surprise. When floodwaters left millions homeless and without access to clean drinking water in a region where cholera remains endemic, health officials could have reasonably assumed infected human waste would seep into water supplies and spread disease. The inability of health networks on the ground to prevent and then detect cholera demonstrates cracks in the country’s health system. What is apparent here is a lack of will and resources. Disease surveillance is especially vital in a post-disaster scenario where steps can be taken, such as treating water with chlorine, to prevent an outbreak.
Haiti had been free of cholera for at least 50 years, but the disease struck and spread rapidly 10 months after the devastating January 2010 earthquake. It reached Haiti’s capital and spread to its neighbor, the Dominican Republic. Since October, more than 114,000 people have become ill and more than 2,500 have died (Editor’s note: updated since original publication).
Haiti lacked resources for basic infrastructure even prior to the earthquake; the cholera crisis is not only costing lives, but also diverting aid from “building back better.” But regardless of the source of the cholera strain, if basic infrastructure and resources to protect Haiti’s vulnerable populations had been in place, cholera’s re-emergence would have been far less devastating.
This particular outbreak draws attention to the practical and political challenges of identifying health risks in humanitarian workers and peacekeepers, many of whom come from developing countries themselves. Evidence suggests that peacekeepers from Nepal, housed at a UN base, may have been the source of the outbreak clustered around the Artibonite River. Cholera outbreaks frequently exacerbate frictions between communities and aid workers – suspicions that have led to riots and murder more than once in recent years. At least two people were killed in Haiti in riots with peacekeepers during November.The delayed decision by the UN to investigate whether the outbreak originated with peacekeepers may have conserved resources for the race to stave off more cases, but did little to build trust between communities and foreign workers. Further violence and protests surrounding the recent disputed presidential election in Haiti do little to ease the devastation and in fact, threaten the relief effort. There has been discussion in Congress of cutting direct aid and suspending visas for Haitian officials until the dispute as been resolved. The Organization of American States is now reviewing the results.MORE
In Africa, Nigeria is experiencing its worst cholera outbreak since 1991, and the disease is crossing borders. An onslaught of cases raised the 2010 death toll to more than 1,500 fatalities out of 40,000 cases. This mortality rate is three times higher than the seasonal cholera outbreaks of 2009, and seven times higher than 2008. Despite Nigeria’s oil wealth, most of the population is impoverished. Two-thirds of rural Nigerians lack access to safe drinking water and fewer than 40 percent of people in cholera-affected areas have access to toilet facilities, according to the Nigerian Health Ministry. A combined lack of will, transparency, and resources mean that cholera epidemics occur annually, and in clusters throughout sub-Saharan Africa.
A century and a half after John Snow’s discovery, we know how to control cholera. Globally, the resources exist, but the question of a collective will remains. For those who lack clean water to drink, to wash, or even proper toilets, the gap between knowing and doing is not easily closed. The international community has shown repeatedly that it can confront cholera outbreaks like those in Haiti, Pakistan, and Nigeria in the midst of crisis. The question remains as to how those efforts can eliminate the conditions that fostered outbreaks in the first place. The answer is not as riveting as the causes that often receive funding: basic infrastructure and resources. Roads, wells, clean water, toilets, education, and the willingness to recognize that if the foundation is not sound, nothing will be able to stand. Sometimes the simplest problems are the most difficult to solve.
Sarah Kornblet is a research fellow at the Global Health Security Program at the Stimson Center. Her research focuses on the International Health Regulations, health systems strengthening, global health diplomacy, the intersection of public health and security, and the potential for innovative and dynamic health policy solutions in developing countries.
Sources: Agence France-Presse, BBC, Washington Post, World Health Organization.
Photo Credit: “UN Peacekeepers Provide Security During Port-au-Prince Food Distribution,” courtesy of flickr user United Nations Photo. -
Friday Podcasts:
Judith Bruce on Empowering Adolescent Girls in Post-Earthquake Haiti
›By ECSP Staff // Thursday, December 16, 2010
“The most striking thing about post-conflict and post-disaster environments is that what lurks there is also this extraordinary opportunity,” said Judith Bruce, a senior associate and policy analyst with the Population Council’s Poverty, Gender, and Youth program. Bruce has spent time this year working with the Haiti Adolescent Girls Network (HAGN), a coalition of humanitarian groups conducting workshops focused on the educational, health, and security needs of the country’s vulnerable female youth population.MORE
Gender-based violence has long been an issue in Haiti, but the problem became even more pronounced in the wake of the January earthquake. HAGN has sought to address the problem by concentrating its community-based programming on “high priority” groups, including girls who are disabled, serve as de facto heads of households, or are aged 10-14.
Bruce asserted that protecting and empowering young girls is critical because upon reaching puberty, “their access to a safe world shrinks dramatically.” With the post-disaster environment adding another layer of challenge, she said “there could be no ambiguity in anyone’s mind that we have to create dedicated spaces for girls who, at least for a few hours a week, feel secure to be themselves and to plan for their long-term safety as well as their development.”
The “Pop Audio” series is also available as podcasts on iTunes.
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