The Quagmire

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Our community is made up of health care folks that do hard things, go the extra mile, work on themselves and their knowledge so that patients get better outcomes. We’re not good all the time. We make mistakes, forget stuff, get grumpy or emotional, slide into tribal behaviour. But we’re working on it. So when someone comes along and shines a light on what’s happening outside our normal frame of practice, shows us patients that can’t get care, who are needlessly dying or suffering, it makes us uncomfortable. We want to do something.

Sometimes I get asked to be the person that turns on that torch, the person that makes everyone else uncomfortable, most recently at the excellent DFTB17. I try to do this with balance, to show another context, but also not to make people feel helpless or shocked. Sometimes I get it right, sometimes not. Without fail though, at least one person always asks me afterwards a variation of ‘What can I do?

The first post – Narrowing The Frame –  looked at:

  • Recognising what you already do
  • Terminology
  • Information and témoignage
  • Be around for someone and learn from them

This is the second post – The Quagmire:

  • Something is not always better than nothing (primum non nocere)
  • Ignorance
  • Aid-as-proxy
  • Lack of meaningful accountability
  • Get political
  • Navigating donation

 

Something is Not Always Better than Nothing (Primum Non Nocere)

Not all aid is good and ‘good aid’ is hard to define. Like in medicine, harm can occur or sometimes nothing is done but at great fanfare and expense. Though intentions are rarely malicious, outcomes can be unhelpful, or worse detrimental. There are many ways to think about it but aid problems mainly revolve around three genesis points that can become the …

1) Ignorance

I don’t mean ignorance necessarily pejoratively, but as a parent term for things such as cultural incompetence and assumptions. The path to aid may be paved with good intentions, but a closer look shows potholes, differences in background and approach between aid-provider and aid-receiver. There are drivers that are perhaps understandable but ultimately harmful: the hero narrative, the saviour narrative, even the narrative about helping people, which can contribute to a power differential where none should exist. These are easy to slip into unwittingly, not helped by the way the media and agencies themselves can present things. And sometimes the people with the potential problem (and often the solution) are not fully included in the discussion.

A flavour of this just from my experiences: a $20,000 pathology machine donated by a large, experienced agency to a place with no power supply to run it or access to maintenance; the US residents who spent a programme-sanctioned 6 weeks ‘teaching’ senior African physicians; the donation of expired drugs and equipment to a low resource setting. These are meant well, but they are not necessarily good things.  

So, why do they happen?

Some of them happen because of a perceived knowledge differential or the hero/saviour thing.  And some of them happen because of misunderstandings.

Let’s go back to the pilot slumped over in his cockpit in the dictionary definition of aid at the top.  He might just be sleeping after many hours of no rest, waking him up could be he last thing he needs. Alternatively he might have had a cardiac arrest, or be drunk and about to fly the plane. Who knows? It’s all about context, we need to understand what’s going on in order to understand need. So you look around, is there an empty vodka bottle on the floor? Has he just flown in on a long-haul? Does he have a pulse? (*not necessarily in that order) The trouble is, whilst this analogy is simple, most situations where people are trying to provide aid are not.  However, as @thefrancis6 said in his DFTB talk you can’t be paralysed by indecision (more on that in blog 3).  If the pilot is in cardiac arrest, a year of analysis before starting CPR doesn’t work.

Ignorance, for want of a better term, will always be there.  Its recognition and incorporation into our response is part of its mitigation, as is asking the people that know and being adaptable as unknowns become knowns.  It becomes part of the Trifecta of Turd usually when it is not recognised, or if recognised not addressed.

2) Aid-As-Proxy

This is when something looks like aid, but aid isn’t the primary goal.  In one of the worst ‘aid-as-proxy’ examples, something that definitely wasn’t aid was dressed up to look like this, with extraordinarily far-reaching ramifications.

However, there are more subtle types of aid-as-proxy.  For example, Australia’s Department of Foreign Affairs and Trade (DFAT) are open about their approach to aid here.   In the flowchart, DFAT clearly state that their goal with AusAid is ‘promoting Australia’s national interests by contributing to sustainable economic growth and poverty reduction’. Aid funded by the United Nations, World Bank, IMF, religious groups and many other institutions also comes with specific agendas. Direct government-to-government aid can be used as a political carrot/stick that has little to do with alleged beneficiaries.

I want to be clear here that there is important contributory work and ‘good aid’ with this kind of financial backing.  But it’s key to consider donor goals as they may impact outcomes, in the same way we look at COI in research.

It could be said that every agency has some sort of COI, as every researcher has their agenda, even if it is just about generating ongoing funding.  However, agencies with a broad base of private, non-governmental, individual donors are likely to have the least aid-as-proxy conflicts.

 

Research Controversies

Whilst not quite aid-as-proxy, it’s worth noting that research conducted by high-resource institutions in low resource settings is complex and can be harmful. One deeply unethical and complex case was Pfizer with Trovan in Nigeria.  Amiodarone treatment in ebola was also highly controversial for not being approved research. In less dramatic examples, the PhDs and academic papers regularly generated may do little for research subjects and a lot for authors’ careers.

 

Flag Planting

This is when agencies set up an intervention in an area where there is a lot of media attention or funding opportunities with a (sometimes unwitting) primary goal of being seen as relevant, profile raising or fundraising. This can sometimes do harm or be ineffectual rather than responding to actual needs, as well as drawing resources away from less ‘sexy’ problems.

Many agencies and individuals gave time and money during the 2004 Tsunami and the 2014 ebola outbreak, for example. All sorts of initiatives and funding were thrown at these high-profile disasters, when every day more are killed by less novel conditions like malaria and diarrhoea.  Diarrhoea is not sexy apparently;) And then there’s Haiti… where thousands died of cholera with 12,000 NGO’s sitting in country.  This was flag-planting but it was also the full Trifecta.

 

3) Lack of Meaningful Accountability

If you were given money to do something but no-one was watching you do it, would you do it? Probably yes.

What if someone with unimaginable amounts of money gave you $20 to buy a $4 coffee, thinking it cost $20.  Would you give this person the change? Probably yes.  You’re a great person;)

What if you were traumatised, had nothing, lived in a country with endemic corruption and didn’t know what coffee was or why someone wanted it.  What if that $16 would feed your family for a month? What if the person giving you the money didn’t speak your language, looked different to you and you didn’t know why they were in your country let alone trust them?

What if, in this situation, the barista would write you a receipt saying the coffee cost $20 if you gave him $2 commission?

What if you didn’t even have to present the coffee, all you had to do was write a report to say that the coffee had been bought and it cost $20?

This is a simplistic metaphor… but your resolve to give back the change ebbs away, right?

If accountability is limited to report writing which then gets sent up to the capital and then headquarters (a model followed by many agencies providing aid) then the $16 dollars may go in someone’s pocket.  If you are lucky you will get the coffee, but it’s equally likely that the coffee will be mysteriously spilled and a report written about that, or that you will get some granules mixed up to look like a cappuccino, or by the time it arrives you will have moved on to another project and the new person doesn’t even like coffee. So they order a tea…

You can see how it goes.

Meaningful accountability can be expensive, so the proportion of funding afforded to accountability has to be balanced, but it should be there.

 

Outcome Indicators

We struggle with meaningful, patient oriented outcome indicators. It is tempting to measure the things that are easy to measure, rather than the things that might be more meaningful but more difficult. For example, a bump in creatinine after contrast that has no discernible impact on the patient but translates into the entity of contrast-induced nephropathy and causes much wringing of hands (*over-simplified for word count;).  This is just as much if not more of a problem in aid provision.  Many interventions are well meaning but their impact is unknown, and, as in medicine, the outcome is the result of a constellation of inputs, some known, some unknown and some unknowable.

 

In Summary…

Imagine: people with a hero complex who do not understand the context funded by an agency with a non-aid related mandate that must be met, paying money for interventions where outcome indicators have not been well defined and for which there is no oversight beyond report writing by individuals with complex influencers.  Can you see how it goes bad? Oh, it can go bad.  It can become the Trifecta of Turd.

So what?

Ugh. How does this help you with ‘what can I do?’

Take a breath. Not all aid is good, but that doesn’t mean that no aid is good. Important, contributory things are done on a micro level every day and on a macro level at regular intervals. Intentions are good, remember what they were when you asked ‘What can I do?’

What I am trying to get at is… be a critical thinker (you already are, but apply it to this). Try and figure out who is doing more good than bad, and therefore who you could support and how, using the analytical tools you already have. Look at things like: does this agency/intervention have…

  • Support and involvement of the people it is designed to help
  • Independence – financial and political
  • Experience doing what they are trying to do
  • Meaningful, defined patient oriented indicators
  • On ground oversight and accountability
  • Lack of highly critical ‘expose’ type news stories*

*if you do bad for long enough someone will write about it – I synonymise this with considering bad reports about a trainee from colleagues in your evaluation.

 

Relying solely on agency-produced reports about activities is a bit like relying on big pharma drug studies in terms of COI. Google it, look at SoMe, ask around, think about the aims of the agency or institution that you are considering supporting or working for (a framework is offered below). Permit ambiguity and complexity, and the real possibility that you could accidentally contribute to harm or an expensive nothing.  

 

Be Political

This is an interrelated part of the quagmire. Part of the nuance of need is that the hand that gives is often the hand that taketh away. Much of what is interfering with equity globally and contributing to conflicts and humanitarian crises in far-flung places is happening at home.  Think about getting involved in political activism on some of the policies your own government is responsible for.  Actually impacting change at this level is very difficult, but understanding how domestic and foreign policy is linked to what is happening overseas is worthwhile. Consider the butterfly effect, even our small acts can be considered political: the clothes we wear, the food we buy, we are much more interconnected than we like to think. Use your vote, write to your MP, protest, talk about politics and encourage others to get involved.

 

Navigating Donation

Time

Post 3 will look at working overseas for longer periods.  This is about short periods and remote support options.  I have not made specific recommendations about entities to which you could give time or money, more a few pointers to help you evaluate and decide.

There is a frank but insightful article on voluntourism here, but teaching for short periods in contexts where EM is developing can be a useful support or start to a broader relationship. However, it needs to be relevant, led by those on ground and come with a cognisance that learning will be bilateral.  To be honest when I have been lucky enough to be asked to do this I have generally learnt more than I have taught.

One trap is to be donor driven: having a resource (expertise, time, professional development leave/money) and trying to match it to a problem that is likely to be much more complex. To mitigate this, we need to recognise it and really get into what would be beneficial educationally from those already on ground.  Use a short visit as a time to build relationships and be more relevant next time, or during remote support or mentorship. Busy as you are, try not to see it as a holiday or fitting into your life somehow (more on this in post 3).

Mentorship is an option that can occur remotely as the world becomes more connected. Informal Whatsapp groups are now common between colleagues in low resource (and higher resource) settings.  Telemedicine programmes are evolving all the time, particularly in conflict zones. Some FOAMed entities like Radiopaedia.org are used by health care providers in low resource settings.  Contributing to sites like this can have far-reaching impact. 1:1 mentorship programmes exist where more experienced docs can support junior staff in developing contexts remotely.  Unless you are very experienced in the context, it’s probably advisable to listen for a good long time before you start giving advice to mentees.

Money

Giving money is easy to do, but can seem hard to navigate.

Much of what is important about trying to manoeuvre through this is detailed above, but also think about the context you want to support and what are you interested in helping to achieve there. Do you want your cash to go somewhere specific or is it more the ethos of an organisation that you are interested in? Do you want to support individuals, governmental structures, agencies supporting development or emergency humanitarian response?

A framework you could consider when evaluating:

Initial agenda

  • Ethos – what the organisation says it does and why
  • Donor control – who funds this project and what their agenda is

Outcome

  • This entity is trying to do something important and needed
  • Realism – this entity is trying to do something feasible
  • Operational competency – track record of safe and competent ops
  • Relevance
  • Quality – outcomes are context-meaningful and reported

Accountability

  • Transparency – how public this entity is with its finances and activities
  • Accountability structure – how accountability works in this entity

http://www.changepath.com.au is a site that collects info on charities and rates their transparency and governance, it relies heavily on annual reports but can be a good start.  I also use personal knowledge after nearly ten years of involvement with various things – please get in touch if you have specific questions, I may be able to help or know someone who can. Perhaps most importantly, send the organisation or person an email asking some questions, their response to this will help guide your evaluation.

Quagmire?

Yep it’s a quagmire, but it’s worth wading in.

Next time…

Post 3 (Demystifying And De-mything Practicalities) will go into:

  • Options for and practicalities of working in ‘emergency humanitarian aid’
  • Options for and practicalities of working in ‘development’
  • Research
  • Other stuff

 

I am very happy to discuss any questions or comments

As ever, these are my opinions and do not represent any of the entities that I work for or have worked for.

@Turtle1doc  – nat_thurtle@yahoo.com

Many thanks to: @mina_el_naguib @kat__evans @codingbrown and @drantonyjc for wise words @gracesyleo for graphics

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Natalie Thurtle is a medical doctor and has been on a field assignment with Médecins Sans Frontières in Al Ruwayshed, Jordan. Stuck on the Jordanian side of the border she couldn’t access the patients stranded in Syria in an area called the Berm. She tells the fictional story of Ibrahim, a Syrian child wandering in this place she can’t access.

Author: Natalie Thurtle

Natalie Thurtle is a medical doctor and has been on a field assignment with Médecins Sans Frontières in Al Ruwayshed, Jordan. Stuck on the Jordanian side of the border she couldn’t access the patients stranded in Syria in an area called the Berm. She tells the fictional story of Ibrahim, a Syrian child wandering in this place she can’t access.