So have you ever wondered what it would be like to live in a place with no rules? That sounds pretty cool.
You wake up one morning, however, and you discover that the reason there are no rules is because there's no government, and there are no laws. In fact, all social institutions have disappeared. So there's no schools, there's no hospitals, there's no police, there's no banks, there's no athletic clubs, there's no utilities.
Well, I know a little bit about what this is like, because when I was a medical student in 1999, I worked in a refugee camp in the Balkans during the Kosovo War. When the war was over, I got permission—unbelievably—from my medical school to take some time off and follow some of the families that I had befriended in the camp back to their village in Kosovo, and understand how they navigated life in this postwar setting.
Postwar Kosovo was a very interesting place because NATO troops were there, mostly to make sure the war didn't break out again. But other than that, it was actually a lawless place, and almost every social institution, both public and private, had been destroyed. So I can tell you that when you go into one of these situations and settings, it is absolutely thrilling...for about 30 minutes, because that's about how long it takes before you run into a situation where you realize how incredibly vulnerable you are.
For me, that moment came when I had to cross the first checkpoint, and I realized as I drove up that I would be negotiating passage through this checkpoint with a heavily armed individual who, if he decided to shoot me right then and there, he actually wouldn't be doing anything illegal. But the sense of vulnerability that I had was absolutely nothing in comparison to the vulnerability of the families that I got to know over that year.
You see, life in a society where there are no social institutions is riddled with danger and uncertainty, and simple questions like, "What are we going to eat tonight?" are very complicated to answer. Questions about security, when you don't have any security systems, are terrifying. Is that altercation I had with the neighbor down the block going to turn into a violent episode that will end my life or my family's life?
Health concerns when there is no health system are also terrifying. I listened as many families had to sort through questions like, "My infant has a fever. What am I going to do?" "My sister, who is pregnant, is bleeding. What should I do? Who should I turn to?" "Where are the doctors, where are the nurses? If I could find one, are they trustworthy? How will I pay them? In what currency will I pay them?" "If I need medications, where will I find them? If I take those medications, are they actually counterfeits?" And on and on. So for life in these settings, the dominant theme, the dominant feature of life, is the incredible vulnerability that people have to manage day in and day out, because of the lack of social systems.
And it actually turns out that this feature of life is incredibly difficult to explain and be understood by people who are living outside of it. I discovered this when I left Kosovo. I came back to Boston, I became a physician, I became a global public health policy researcher. I joined the Harvard Medical School and Brigham and Women's Hospital Division of Global Health. And I, as a researcher, really wanted to get started on this problem right away. I was like, "How do we reduce the crushing vulnerability of people living in these types of fragile settings? Is there any way we can start to think about how to protect and quickly recover the institutions that are critical to survival, like the health system?" And I have to say, I had amazing colleagues. But one interesting thing about it was, this was sort of an unusual question for them. They were kind of like, "Oh, if you work in war, doesn't that mean you work on refugee camps, and you work on documenting mass atrocities?"—which is, by the way, very, very, very important.
So it took me a while to explain why I was so passionate about this issue, until about six years ago. That's when this landmark study that looked at and described the public health consequences of war was published. They came to an incredible, provocative conclusion. These researchers concluded that the vast majority of death and disability from war happens after the cessation of conflict. So the most dangerous time to be a person living in a conflict-affected state is after the cessation of hostilities; it's after the peace deal has been signed. It's when that political solution has been achieved. That seems so puzzling, but of course it's not, because war kills people by robbing them of their clinics, of their hospitals, of their supply chains. Their doctors are targeted, are killed; they're on the run. And more invisible and yet more deadly is the destruction of the health governance institutions and their finances.
So this is really not surprising at all to me. But what is surprising and somewhat dismaying, is how little impact this insight has had, in terms of how we think about human suffering and war. Let me give you a couple examples.
Last year, you may remember, Ebola hit the West African country of Liberia. There was a lot of reporting about this group, Doctors Without Borders, sounding the alarm and calling for aid and assistance. But not a lot of that reporting answered the question: Why is Doctors Without Borders even in Liberia? Doctors Without Borders is an amazing organization, dedicated and designed to provide emergency care in war zones. Liberia's civil war had ended in 2003—that was 11 years before Ebola even struck. When Ebola struck Liberia, there were less than 50 doctors in the entire country of 4.5 million people. Doctors Without Borders is in Liberia because Liberia still doesn't really have a functioning health system, 11 years later.
When the earthquake hit Haiti in 2010, the outpouring of international aid was phenomenal. But did you know that only two percent of that funding went to rebuild Haitian public institutions, including its health sector? From that perspective, Haitians continue to die from the earthquake even today.
I recently met this gentleman. This is Dr. Nezar Ismet. He's the Minister of Health in the northern autonomous region of Iraq, in Kurdistan. Here he is announcing that in the last nine months, his country, his region, has increased from four million people to five million people. That's a 25 percent increase. Thousands of these new arrivals have experienced incredible trauma. His doctors are working 16-hour days without pay. His budget has not increased by 25 percent; it has decreased by 20 percent, as funding has flowed to security concerns and to short-term relief efforts. When his health sector fails—and if history is any guide, it will—how do you think that's going to influence the decision making of the five million people in his region as they think about whether they should flee that type of vulnerable living situation?
So as you can see, this is a frustrating topic for me, and I really try to understand: Why the reluctance to protect and support indigenous health systems and security systems? I usually tier two concerns, two arguments. The first concern is about corruption, and the concern that people in these settings are corrupt and they are untrustworthy. And I will admit that I have met unsavory characters working in health sectors in these situations. But I will tell you that the opposite is absolutely true in every case I have worked on, from Afghanistan to Libya, to Kosovo, to Haiti, to Liberia—I have met inspiring people, who, when the chips were down for their country, they risked everything to save their health institutions. The trick for the outsider who wants to help is identifying who those individuals are, and building a pathway for them to lead.
That is exactly what happened in Afghanistan. One of the unsung and untold success stories of our nation-building effort in Afghanistan involved the World Bank in 2002 investing heavily in identifying, training and promoting Afghani health sector leaders. These health sector leaders have pulled off an incredible feat in Afghanistan. They have aggressively increased access to health care for the majority of the population. They are rapidly improving the health status of the Afghan population, which used to be the worst in the world. In fact, the Afghan Ministry of Health does things that I wish we would do in America. They use things like data to make policy. It's incredible.
The other concern I hear a lot about is: "We just can't afford it, we just don't have the money. It's just unsustainable." I would submit to you that the current situation and the current system we have is the most expensive, inefficient system we could possibly conceive of. The current situation is that when governments like the US—or, let's say, the collection of governments that make up the European Commission—every year, they spend 15 billion dollars on just humanitarian and emergency and disaster relief worldwide. That's nothing about foreign aid, that's just disaster relief. Ninety-five percent of it goes to international relief agencies, that then have to import resources into these areas, and knit together some type of temporary health system, let's say, which they then dismantle and send away when they run out of money.
So our job, it turns out, is very clear.
We, as the global health community policy experts, our first job is to become experts in how to monitor the strengths and vulnerabilities of health systems in threatened situations. And that's when we see doctors fleeing, when we see health resources drying up, when we see institutions crumbling—that's the emergency. That's when we need to sound the alarm and wave our arms. OK? Not now. Everyone can see that's an emergency, they don't need us to tell them that.
Number two: places like where I work at Harvard need to take their cue from the World Bank experience in Afghanistan, and we need to—and we will—build robust platforms to support health sector leaders like these. These people risk their lives. I think we can match their courage with some support.
Number three: we need to reach out and make new partnerships. At our global health center, we have launched a new initiative with NATO and other security policy makers to explore with them what they can do to protect health system institutions during deployments. We want them to see that protecting health systems and other critical social institutions is an integral part of their mission. It's not just about avoiding collateral damage; it's about winning the peace.
But the most important partner we need to engage is you, the American public, and indeed, the world public. Because unless you understand the value of social institutions, like health systems in these fragile settings, you won't support efforts to save them. You won't click on that article that talks about "Hey, all those doctors are on the run in country X. I wonder what that means. I wonder what that means for that health system's ability to, let's say, detect influenza." "Hmm, it's probably not good." That's what I'd tell you.
Up on the screen, I've put up my three favorite American institution defenders and builders. Over here is George C. Marshall, he was the guy that proposed the Marshall Plan to save all of Europe's economic institutions after World War II. And this Eleanor Roosevelt. Her work on human rights really serves as the foundation for all of our international human rights organizations. Then my big favorite is Ben Franklin, who did many things in terms of creating institutions, but was the midwife of our constitution.
And I would say to you that these are folks who, when our country was threatened, or our world was threatened, they didn't retreat. They didn't talk about building walls. They talked about building institutions to protect human security, for their generation and also for ours. And I think our generation should do the same.