Peacekeeping Gone Awry

Source: CNN.com

In her talk, Dr, Emilie Calvello expressed consternation about the multiple NGOs that flooded Haiti in the wake of the earthquake and the lack of partnership and cooperation with the local Haitian healthcare providers. She particularly emphasized that the willingness to help was not enough—we must help in the right way. This includes understanding the cultural perspectives of the Haitians as well as engaging their abilities to improve the crisis at hand.

This week, we saw how even in a disaster situation, we must view those we aid as “co-producers” of health, no matter how strong the impulse is to see them as helpless and suffering. In the aftermath of the earthquake in Haiti and the resulting destruction of public infrastructure, an epidemic of cholera has swept the nation with an equally dangerous wave of chaos. Now, reports have emerged that Haitians are violently protesting against UN peacekeepers. At first glance, this seems ludicrous. How can people protest against the malicious spread of bacteria? What good could come from fighting the “peacekeepers” that are there to help?

With a critical eye, however, it is clear that this cholera epidemic has only served to open the floodgates for the tension and mistrust that had festered between the Haitian population and the foreign occupiers. The situation is complex. The spread of cholera is a public health crisis, but we must realize that all diseases are socially, culturally, and politically grounded. Many Haitians from the slums, mistakenly but understandably, view the cholera treatment centers as hotspots for spreading the disease. Upcoming elections in Haiti are suspected to be the motivations for the cholera-related riots. It is almost overwhelming to comprehend and assess it all. Nevertheless, it is a necessary exercise, as disaster response has spiraled into a nationwide epidemic and now to political unrest. From this compounding crisis, we see the increasing urgency of appropriate international interventions, lest we face the unintended consequences of our supposed altruism.

“Co-producing” Health

Ever since the United States boldly asserted its influence over the international arena in the post-World War II era, the topic of its role in the development and progress of foreign countries has long been debated. This question reaches the U.S. medical profession today as we seek to better understand our role as healthcare providers in a time of growing global interconnectedness. One way of assessing our own international involvement is to evaluate our characterization of the presumed “target population.” Our view of the needs and responsibilities of those we treat abroad dictates our approach to global health.

We often preoccupy ourselves with the logistics of our own medical resources—how many doctors and supplies can we allocate, and how many clinics can we build? Moreover, we too easily view the population at hand as a model of a single disease or condition. We simply declare that we are going to “help HIV patients in Africa” and that becomes our singular goal. Yet this ignores the very social capital and means that are possessed by the persons we seek to help. We overlook the fact that health is not an isolated state of being, but that it is regulated by a series of social, cultural, and even political levers. As such, we should understand people as integral participants in their personal health maintenance and as key components of a larger social network. Earlier this year, Dr. Julio Frenk, Dean of the Harvard School of Public Health as well as the former Minister of Health of Mexico, wrote about expanding our view of global health systems through understanding a person in five different roles: patient, consumer, taxpayer/financier, political citizens, and co-producers of individual and societal health (Frenk, PLoS, 2010). If we do not see global health populations in these contexts, we not only provide an inadequate service but we miss the opportunity to build sustainability and self-sufficiency within the developing society. Such a sentiment is reflected in recent calls to action to develop an “International Health Service Corps” in which health care workers would engage in medical service and capacity-building partnerships abroad as an act of diplomacy (Kerry et al, NEJM, 2010).

Global health involvement of the U.S. is not a question of whether or not we should be involved. In a globalized age, international communication and exchanges are inevitable and necessary. The question is about the particular way in which we are going to partner with the local communities to implement the most effective health interventions and systems possible.  Global health is about how we can make something better overseas than if we had not been involved at all. More importantly, however, it is about how the people abroad can make something better than if they had not been involved at all.

 

Live from Hopkins: Secretary Clinton on the US Global Health Initiative

For those of you who are in Baltimore, Secretary of State Hillary Clinton will be paying you a visit on Monday to discuss the Obama administration’s Global Health Initiative. That the Secretary of State is giving this talk underlines the important role of aid in the US’s foreign policy and diplomacy strategy in the developing world. Recently we have seen how various groups are competing for “the hearts and mind” of the populations devastated by the floods in Pakistan by offering the desperately needed aid that, many complain, the government is incapable or unwilling to provide.

But of course, the union of aid and diplomacy is a double-edged sword. The diplomatic fringe benefits can motivate the governments of developed nations to invest more in aid, and to shift this aid towards health and education efforts that have a more direct impact on communities (as opposed to say, massive infrastructure projects that tend to create the perfect opportunity for corrupt officials and businesspeople–not that global health efforts are immune from corruption!), but if diplomacy is the primary motivation, there is a significant risk that most decisions will be based not on the best interest of the communities in need, but rather on the political interests of those in power.

Unfortunately only SAIS students and staff will be allowed to attend the event in person, but there will be a live webcast accessible at http://www.sais-jhu.edu/.

Blurb from the Center for Global Health:

Hillary Rodham Clinton, U.S. Secretary of State, will speak at the Johns Hopkins University Paul H. Nitze School of Advanced International Studies (SAIS) on Monday, August 16 at 11:30 a.m.

Secretary Clinton will speak about “The Global Health Initiative: The Next Phase of American Leadership in Health Around the World.” The Global Health Initiative is a centerpiece of the Obama Administration’s foreign policy and an expression of U.S. values and leadership in the world. Secretary Clinton will describe the Global Health Initiative’s core principles, and call on governments, organizations and individuals to join the United States in pursuing a sustainable approach for delivering essential health services to more people in more places.

The soft power of global health diplomacy

We think a lot about global health diplomacy from the U.S. or western European perspective — foreign aid, development, and so on. Much of the international health movement has been structured along these lines: top-down interventions created in Geneva, formalized as WHO (and other) guidelines, and implemented by clusters of dedicated professionals. On the other hand, grassroots organizations work with community leaders and health workers in developing countries to build upward. And then there are those renegade MSF people, who get in there and provide the sheer grit, skill, and manpower to save lives, day to day, through wars and natural disasters. All of this has led to some amazing outcomes.

Why, then, this lingering sense that global health efforts represent a black hole of time and money? Foreign aid is never quite enough, workforce restructuring never fully realized (“brain drain”, I would argue, often takes an unfair share of the blame for this; yes, it’s a problem, but aren’t there others?), and a significant portion of the world’s population remains without access to basic nutritional and medical care.