Stabilizing and rebuilding state infrastructure in post-conflict settings has been increasingly recognized as critical to aiding the population and preventing renewed conflict. The United States has increasingly invested in rebuilding health systems, and in some cases assisting in the delivery of health services for the first time.

While global health concerns have recently received significant attention, as witnessed by President Obama’s Global Health Initiative, the importance of health system reconstruction to stabilization efforts remains unevenly recognized. On November 10, 2009, experts met at the Global Health Council’s Humanitarian Health Caucus to discuss investing in health services in the wake of war and the challenges of funding this investment.

“Deconstruction from violence extends beyond the time of war and often leads to severe damage of health infrastructure, decreased health workers, food shortages, and diseases…resulting in increased morbidity and mortality from causes that are not directly related to combat,” shared Leonard Rubenstein, a visiting scholar at Johns Hopkins School of Public Health. Rubenstein argued that while relieving suffering in post-conflict settings should be a sufficient reason to include health reconstruction in U.S. foreign policy, policymakers narrowly define rationales for engagement based on claims that investments increase peace and improve the image of the U.S. government.

Investing in Health Systems Builds State Legitimacy

The evidence for investing in health systems to deter future conflict is limited and this approach is dangerous, according to Rubenstein, because it distorts spending decisions and fails to consider comprehensive capacity development strategies. Additionally, the Department of Defense’s approach of “winning the hearts and minds” is too short-term and neither linked to “system-building activities that are effective and sustainable…nor consistent with advancing the health of the population,” he said.

Instead, Rubenstein recommended that the United States invest in health systems after conflict because it advances state legitimacy. Although additional evidence is necessary, Rubenstein maintains that the promotion of state legitimacy enhances the perception that the government is responding to their long-term needs and encourages local ownership and accountability. Developing health systems in post-conflict settings is complex and cannot be done quickly, he noted, and thus increased financial and human resource capacities will be essential.

Coordination and Transition Funding

“We need to recognize that the U.S. is not the only funder, as there are many stakeholders involved,” argued Stephen Commins, strategy manager for fragile states at the International Medical Corps. Commins argued that there is a “desperate need to coordinate donor funding … both within and across government systems, as well as an increased need for transparent donor tracking systems.”

As countries come out of conflict and start to gain government legitimacy, they need increased support to stabilize conflict and avoid collapse. Transition funding for health systems needs to support both short and long-term efforts, maintained Commins, but unfortunately the donors driving these timelines are often driven by self-interest, not the rights of the individual living in conflict.

Without a transparent donor tracking system, it is hard to demonstrate actual monetary disbursements versus commitments, so Commins called for a system that tracks allocations and spending in real time. These are not our countries, he argued, and responding to health systems in post-conflict settings should be tailored to the country’s needs, not the donor’s. He also called for increased research that describes, over time, the costs for rebuilding and transitioning from international NGO-driven systems to self-sustained governments.

Rebuilding Health Systems in Sudan

George Kijana, health coordinator in southern Sudan for the International Rescue Committee, discussed reasons for why Sudan’s health system remains poor five years after conflict. According to Kijana, the government in Southern Sudan has not been held accountable by its donors, leading to a breakdown in infrastructure and a lower quality of health workers.

Additionally, a majority of the available health data comes from non-state actors that are not easily accessible. Kijana shared that in order for Sudan to move forward, more research and data are needed to help target long-term capacity building projects, as well as short-term interventions that address infant and maternal mortality. While progress is slow, he pointed out encouraging signs of progress, as the Ministry of Health now recognizes their weaknesses and positively engages with its development partners such as the United Nations.

Photo: Romanian Patrol administers medical treatment to Afghan communities, courtesy of Flickr user lafrancevi.

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Celebrity philanthropists such as Bono, Angelina Jolie, and George Clooney have shined their star power on global issues like AIDS, genocide, and refugees. In last month’s Vogue, supermodel Christy Turlington turned the light on one of the most overlooked problems: maternal mortality.

The climate community is under increasing pressure to help the developing world, especially those at the “bottom of the pyramid.” The people who did the least to cause climate change will suffer its effects the most.

A critical part of the solution to this problem will be enhancing market-based incentives for climate-friendly behavior. The projects that generate credits for sale in the carbon markets vary widely in scale. However, the most successful have focused on large, localized sites, such as the smoke stack of a single plant. These “centimeter-wide, kilometer-deep” projects are easy to monitor and verify.

In contrast, most projects that benefit the poor are “a kilometer wide, a centimeter deep,” with each family across a large territory producing a small emissions reduction. Monitoring and tracking these community-based projects is usually cost-prohibitive.

DRC: Reducing Emissions and Improving Security

A Mercy Corps project in the refugee camps in the eastern Democratic Republic of the Congo (DRC) seeks to improve the security of women and children while simultaneously reducing carbon emissions.

In the war-ravaged province of North Kivu, the total number of Internally Displaced Persons (IDPs) exceeds 850,000. Demand for resources, particularly fuel wood, vastly exceeds the available supply. To collect wood, women and children have to leave the relative safety of the refugee camps, making them vulnerable to sexual assault and child abduction by rebel groups and the army. Mercy Corps surveys indicate that nine percent of women in camps have been raped or otherwise assaulted.

Mercy Corps installs fuel-efficient stoves that reduce the need for dangerous trips into the forest. A commercial carbon broker develops carbon credits from the reduction in emissions that arises from the use of stoves instead of open fires. The upfront funding from the broker supplements a UNHCR grant supporting the project, and serves to help more than 20,000 families in one of the most dangerous places on Earth.

This extreme example is one of relatively few carbon projects generating revenue that benefits vulnerable people. Yet if this kind of project can be successful in the DRC, larger projects in safer countries may be able to generate massive emissions reductions. The Copenhagen conference needs to set the stage for these types of market incentives for better climate behavior.

Raising a REDD Flag

A relatively new, UN-backed initiative known as Reduced Emissions from Deforestation and Forest Degradation (REDD) seeks to compensate forest-rich countries for protecting or regenerating their forests. However, REDD may have the unintended consequences that further erode the human rights of marginalized people dependent on those forests.

For decades, tropical forests have been logged legally and illegally by states and private companies, without any input from or compensation to indigenous forest communities, who, in many cases, were displaced or worse.

REDD thus raises a troubling question: If countries can generate carbon revenues through REDD, to whom do the revenues belong, and how will they be allocated? Many forestry ministries have a long history of corruption and mismanagement. There are already signs of ministries competing over putative REDD funds. And high-level discussions in only a few countries have included the role of communities and civil society in implementing REDD and distributing revenues.

The Copenhagen conference will be a critical milestone in the global fight to address climate change. Yet it raises significant and far-reaching questions concerning economic development and human rights of the world’s most vulnerable citizens that must not be swept under the rug.

Jim Jarvie is director of climate change, environment, and natural resources at Mercy Corps. In a recent video interview, he spoke to ECSP about how humanitarian groups are responding to new climate challenges.

Photo: Stoves that are more fuel-efficient not only help curb rapid deforestation, but help women spend less time gathering wood in dangerous areas. Courtesy Dee Goluba/Mercy Corps.

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Did you notice the rash of AFRICOM coverage last week? The Washington Post and the Washington Times (as well as the military’s own Stars and Stripes) published articles on the U.S. military’s newest combatant command and its attempts at military-to-military cooperation and hearts-and-minds diplomacy in Africa.

As part of a seven-month operation the military is calling the Africa Partnership Station, the USS Nashville is attempting to help stabilize the waters off of West Africa, which are plagued by illegal fishing, drug trafficking, and illegal migration, as well as robberies and kidnappings in the Niger Delta. According to the International Maritime Bureau, these waters are now the second-most dangerous in the world, after Somalia’s.

The Post aptly noted that the Nashville’s “mission appears to be as much about wooing Africa as about teaching maritime security.” Each time the Nashville docks, military doctors offer free checkups, and sailors repair local buildings and train host-country soldiers. This low-profile approach seems designed to allay Africans’ earlier fears of U.S. colonialism, which forced the U.S. military to headquarter AFRICOM in Germany instead of Africa.

Why the sudden surge in publicity for AFRICOM, when it’s been doing these kinds of outreach and confidence-building activities for more than a year? Perhaps President Obama, Secretary of State Hilary Clinton, and others in the new administration see AFRICOM as an example of a foreign policy that places as much emphasis on diplomacy and development as on defense. Indeed, even Secretary of Defense Bob Gates, who was appointed by former President Bush, has called for a rebalancing of the instruments of U.S. power; in 2007, he said, “We must focus our energies beyond the guns and steel of the military, beyond just our brave soldiers, sailors, Marines, and airmen. We must also focus our energies on the other elements of national power that will be so crucial in the coming years.”

Photos: Top—Portugal Navy Lieutenant Commander Antonio Mourinha and a Gabonese Sailor inspect a holding bay for fish after boarding an illegal fishing vessel during Africa Partnership Station (APS) Nashville’s fisheries engagement April 29, 2009. (U.S. Navy photo by Petty Officer 2nd Class David Holmes) Bottom—Chief Machinist’s Mate Brian Wallace, embarked with USS Nashville for Africa Partnership Station (APS), conducts training on small boat engine repair and maintenance during a 13-day port visit to Cameroon, April 6, 2009. (U.S. Navy photo by Petty Officer 3rd Class Matthew Bookwalter)

“If you tell the world you’re going to do something and they go, ‘Yeah…?’ it’s probably that you’re making an incremental change in something that the world is already doing reasonably well,” said renowned inventor Dean Kamen at a May 2009 meeting co-sponsored by the Wilson Center’s Environmental Change and Security Program and Program on Science, Technology, America, and the Global Economy. “I’d rather work on the really big stuff.”

His track record proves it: He holds more than 400 U.S. and international patents, and his most famous inventions include an implantable insulin pump, a portable dialysis machine, and an artificial arm, as well as the Segway personal transporter.

Kamen now seeks to provide clean water to the 1.1 billion people who lack it with the Slingshot, a washing machine-sized device that uses just 500 watts of electricity to produce 10 gallons of clean water an hour.

Tackling the Big Problems: Water and Power

Kamen’s career as an inventor began in high school, when he would invent medical devices for his older brother, a doctor. The Slingshot grew out of a portable dialysis machine Kamen developed for patients with renal failure. After inventing a way to make perfectly sterile water for the dialysis machine, he explored whether he could adapt the water-purification technology for the developing world, where millions of people die each year from dirty water.

The data “take your breath away,” said Kamen. More than one billion people lack access to clean water, and 1.6 billion do not have access to electricity. Kamen thought he could address both of these problems with the Slingshot, which uses a Stirling-cycle generator to vaporize and condense the water, removing the impurities.

The generator runs on any kind of fuel, including the methane gas in cow dung, which is readily available in the Bangladeshi villages where Kamen conducted a six-month test of the Slingshot. The generator not only powers the water vaporizer, but also produces enough surplus electricity to power a light, cell phone, and computer for every household in a small village.

The Skepticism of Experts: A Bigger Problem?

In meetings with the World Bank and other international development organizations, Kamen was told that the Slingshot was more expensive than other ways of purifying water, including chlorine tablets, activated-charcoal filters, and reverse-osmosis desalination. But unlike these technologies, the Slingshot can remove any kind of contaminant from water; does not need filters, membranes, or chemicals; and does not require any technical know-how to use.

Kamen granted that the cheaper technologies might be more practical for urban areas, but argued that the Slingshot could have advantages in remote villages without access to technical expertise or a steady supply of chemicals or other components. He also suggested that microfinance might be a way to overcome the large initial cost of the Slingshot—although he emphasized that his expertise lies in developing the technology, and then partnering with experts who know how to surmount the various barriers to distribution.

“If everything I now say by way of recalling my history here seems to you like I’m frustrated, and angry, and disappointed, it’s mostly because I’m frustrated, angry, kinda disappointed,” said Kamen, adding, “But you’re going to fix all that.” Suggestions from audience members included learning from the experiences of venture capitalists who have invested in water technology in the developing world, as well as partnering with the military and defense contractors to manufacture and distribute the Slingshot.

Water, Electricity, and National Security

Kamen suggested that the Slingshot could be used to support U.S. foreign-policy and national-security objectives. For instance, the U.S. armed forces could bring water and electricity to an Afghani village with the Slingshot and Stirling-cycle generator. A telephone and camera mounted on the generator would provide communications technology.

“I would suspect that the Taliban…would be way more worried that everybody in town is happy, and healthy, and has light, and is communicating and showing pictures of everything going on” than about the threat of attack by the United States, said Kamen.

Photo: Dean Kamen. Courtesy of Dave Hawxhurst and the Wilson Center.

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How Do Recent Population Trends Matter To Climate Change?, from Population Action International, offers the latest research from this constantly changing area of inquiry.

U.S. Global Health and National Security Policy, a timely report by the Center for Strategic and International Studies, examines major threats to human health and international stability, including HIV/AIDS, SARS, pandemic influenza, and bioterrorism.

In the coming decades, Russia will confront “accelerated population decrease; a dwindling of the working-age population; the general ageing of the population; the drop in number of potential mothers; a large immigrant influx; and a possible rise in emigration rates,” warns a new report from the UN Development Programme.

In The National Interest and the Law of the Sea, the Council on Foreign Relations’ Scott Borgerson argues that ratifying the Law of the Sea Convention is vital to protecting the United States’ national security, economic, and environmental interests.

David Sullivan of Enough debates Harrison Mitchell and Nicolas Garrett of Resource Consulting Services (RCS) on the links between conflict and mining in the Democratic Republic of the Congo (DRC). RCS recently published a report arguing that mineral extraction is key to DRC’s development and not the primary cause of conflict in North Kivu.

Responding to the ubiquitous Monsanto ads that ask, “9 billion people to feed. A changing climate. Now what?,” Tod Preston of Population Action International responds, “family planning and empowering women, that’s what!”

Water and War, a publication of the International Committee of the Red Cross (ICRC), outlines how the ICRC provides access to clean water during conflict and humanitarian disasters.

A record-breaking 28,000 people, including five heads of state, participated in the Fifth World Water Forum in Istanbul, Turkey, last month. I was there, too, excited to be discussing this year’s theme, “Bridging Divides for Water.” Much of the conversation centered on how to bridge the remaining divides in meeting the Millennium Development Goals (MDGs)—especially MDG 7, which aims to halve the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015.

While notable progress has been made in many regions of the world, such as China and India, other areas, particularly sub-Saharan Africa, lag woefully behind. According to the most recent numbers (2006) by UNICEF and the World Health Organization, only 31 percent of the population in sub-Saharan Africa has access to sanitation, and there are 38 sub-Saharan African countries where sanitation coverage is less than 50 percent. Access to improved drinking water sources has increased to 64 percent across the region; however, increases in coverage are not keeping pace with population growth, and the current rate of provision is not adequate to meet the MDG drinking-water target.

The Fifth World Water Forum, however, marked a hopeful new development. For the first time, the region of the world with the most serious water challenges, Africa, used the Forum to announce an internally driven water and sanitation agenda with a united voice. With support from the African Development Bank, the African Union and the African Ministerial Conference on Water (AMCOW) unveiled a plan to implement existing political commitments to water and sanitation. An “Africa Regional Paper” informed by the First African Water Week, held in Tunis in March 2008, presents African perspectives on each of the themes of the Forum (global change and risk management; advancing human development and the MDGs; managing and protecting water resources; governance and management; finance; education, knowledge, and capacity development), with a key message of delivering on existing commitments. In response to this agenda, the G8 countries announced increased aid to Africa’s water sector.

The desire to solve the world’s water crisis has generated many reports and frameworks over the years, including the Brundtland Commission’s report “Our Common Future” and the World Water Forum process itself. But perhaps nothing is as effective as a proactive, united stance from sub-Saharan Africans themselves, which could go a long way toward ensuring aid is used appropriately and efficiently. The fact that South Africa will host the Sixth World Water Forum in March 2012 should provide another impetus for meeting water and sanitation targets on the continent.

Hope Herron is an environmental scientist with Tetra Tech, Inc. She is currently researching water security issues in the context of the new U.S. Africa Command and U.S. defense, diplomacy, and development frameworks.

Photo: A Sudanese girl fills a water jug at a pump. Courtesy of Flickr user Water for Sudan.

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U.S. journalists “are by and large dying for the opportunity to go overseas and learn about a whole range of issues, from refugees to human rights,” but often lack the support of their editors—the “gatekeepers”—to do so, said Louise Lief, deputy director of the International Reporting Project (IRP), at a February 26, 2009, event, “Reporting From Uganda: U.S. Media Cover Health, Environment, and Security.” Leif was joined by Paul Hendrie, department editor at Congressional Quarterly (CQ); David Rocks, senior editor at BusinessWeek; and Ben de La Cruz, a staff video journalist at The Washington Post, to discuss the recent IRP Gatekeeper trip to Uganda.

President Museveni’s Surprising Views

“One of the advantages of these trips is when you go with a critical mass of 12 very senior editors…you can often get in to see the head of state,” said Leif, describing the group’s sit-down interview with President Yoweri Museveni of Uganda. One “big surprise for me was President Museveni’s views on population,” which he did not consider a challenge, said Lief, despite the country’s high total fertility rate of 6.7 children per woman.

She was heartened that the country’s poor infrastructure, including bad roads and unreliable electricity, did not deter Ugandan children from obtaining an education. “All along the road in brightly colored clothing there were thousands and thousands of children,” she said. “Some of them were walking for kilometers, but they were going to school.”

Organic Farmers Fight DDT in Uganda

“These things that we deal with in Washington every day have a real impact in the real world,” said CQ’s Paul Hendrie. He wrote a story on the Ugandan debate over using the pesticide DDT to combat the country’s significant malaria problem. “As one expert put it to me, ‘Farmers love DDT because it kills everything,’ and that’s why it was so popular”—and why it was banned in the United States.

“Uganda has developed an industry, a fledgling industry, of certified organic farmers. They’re the leading organic exporter in Africa and thirteenth in the world,” explained Hendrie. Farmers are concerned “that if traces of DDT are found in these products, they’ll be shut out of markets, especially in Europe, their biggest market.”

“It’s kind of ironic then that in Uganda now, today, the fight against the use of DDT is not being so much led by environmentalists as by farmers, and specifically organic farmers,” Hendrie noted.

Investigating Uganda’s Economy

“In a developing country, what is it that moves people, that makes the economy grow?” BusinessWeek’s David Rocks wondered before visiting Uganda.

“One of the companies that struck me was Kiwi Shoe Polish,” he said. Many people keep their shoes “for 10 or 15 years, so you have to keep them shined and polished and in good shape in order to use them.” But Chinese companies have begun counterfeiting the polish, causing Kiwi’s sales to plummet 50 percent in the last year. “It’s the poorest of the poor who are getting ripped off,” he said.

“I think that there is a lot of room for interesting economic and business stories to be done from Africa,” said Rocks, who is a senior editor at the magazine. “I hope to get my people to do more and more of that.”

Seeds of Peace in the IDP Camps

“The focus of my reporting was basically on security issues in the north, in the Gulu region, where there’s been a 20-year civil war,” said Ben de la Cruz, who filmed several videos for The Washington Post documenting the dangers of life in Uganda’s internally displaced persons (IDP) camps. In the online multimedia presentation “Seeds of Peace,” IDPs tell their wrenching stories, and peace mediator (and former Wilson Center Scholar) Betty Bigombe provides historical and political context on Uganda’s civil war.

“Despite the two years of relative peace, lots of people are still living in the camps and are afraid to leave,” de la Cruz explained. “There’s a huge fear factor because of Joseph Kony’s rebels—even though they had a ceasefire, they’re always afraid he’s going to come back.”

Photos: From top to bottom: Louis Lief, Paul Hendrie, David Rocks, and Ben de la Cruz. Courtesy of Dave Hawxhurst and the Woodrow Wilson Center.

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