NGOistan in the Levant

I’ve never been entirely sold on most of the common aid critiques, but here is one I can get behind, full-stop: NGO provision of public services (infrastructure development, education, health care…) allows heads of state to maintain power without addressing those needs. All along the democratic spectrum, this disincentives them from developing the capacity to do so as their economies grow, and may prevent governments from even viewing these elements as a responsibility under their purview.

On a panoramic scale, that sounds like very vague, theoretical role-of-the-state talk – so what? But the consequences are tangible: refugees really don’t think much of aid agencies. What might otherwise be a quasi-libertarian humanitarian pipe dream melts down because the feedback cycle is stilted. No votes, no purchasing power.

I’ve seen this play out most obviously among Palestinian refugees, so that’s what I’m going to talk about here. I’m sure there are better examples – South Sudan comes to mind as a more traditionally-managed NGOistan – but the high-wire aspect of Palestinian politics makes this a particularly interesting case study. My hunch is that the UN/NGO provision model encourages governing parties to focus more than they otherwise would on issues of militarization, shifting public discourse away from immediate needs and toward high-level issues in a way that facilitates the development of international quagmires. Continue reading “NGOistan in the Levant”

NGOistan in the Levant

Hearts & Minds: IS, “NGOs” and State Responsibility in Iraq

IS is repairing roads in Iraq.

Other sources have reported forced marriages to IS militants. Forced marriages – a debatable enough term in a place where choice of suitor is often not really left up to female teenagers at all – contrary though it may seem, may also be seen as a form of economic relief. Families in Iraq’s rural areas are large, and feeding a fifteen-year-old girl during times of conflict becomes something of a burden when that responsibility could just as easily be transferred to a husband (a powerful one who has just experienced a windfall, no less!). Continue reading “Hearts & Minds: IS, “NGOs” and State Responsibility in Iraq”

Hearts & Minds: IS, “NGOs” and State Responsibility in Iraq

Bioterrorism is already here. It just doesn’t look like we expected.

This is a story of unconnected dots.

On October 17 2013, a strain of polio endemic to Pakistan first appeared in Deir al-Zor province, Syria. This virus presumably hitched a ride on a ne’er-do-well from Balochistan who thought supporting the Nusra Front would be a good use of his time and likely had no idea he was infected.

On February 12, the U.S. Department of State launched a new Global Heath Security Agenda. The highlight Secretary Kerry’s op-ed on the launch? The 2003 outbreak of SARS, hyped scourge of Asia, with 8,000 known infections and 775 known deaths. The famed Anthrax attacks of 2001, with 17 infections and five deaths, also made an appearance.

On March 11, an infant in Lebanon presented with paralysis. Unlike Jordan, Lebanon has refrained from establishing formal camps for its refugees in an effort to deter permanent residence — a lesson, perhaps, learned from the influx of Palestinians half a century ago. Continue reading “Bioterrorism is already here. It just doesn’t look like we expected.”

Bioterrorism is already here. It just doesn’t look like we expected.

Burdens of Disease.

People have been asking me lately, as I’ve bounced from place to place, why I find the Middle East an interesting place to pursue global health work. There are about fifty different answers to this, but in short: I think inequality within countries makes for more challenging distribution of resources than inequality between countries, I’m interested in how healthcare can be used as a political tool, and I expect the challenges much of the region faces now to be similar to those some areas of Africa will face in twenty-thirty years. But the easiest explanation is quick and visual.

Continue reading “Burdens of Disease.”


Amman: Round Two

I’m headed back to Jordan this summer for thesis research, fieldwork, and (of course) weekend canyoneering. The original plan was Beirut – still angling to make it back & forth a few times. Here are a few things I’m going to work on while gallivanting about the Levant. All advice, criticism, and insight is more than welcome!

1. Gather some hard data on how immunization rates change during Ramadan.

I’ve been tracking patients that miss their immunizations for about seven months now. We started *just* before Ramadan last year, and noticed a pretty substantial increase in the number of missed appointments during that time. This is probably not surprising to anyone, but it’s also completely unstudied. Delaying immunization by a week or two isn’t a huge problem in an area with decent herd immunity, but waiting a full month before maybe forgetting about it, when migrants and streaming in and out from a warzone where hospitals are being bombed, when polio strains are blooming across the border, when we’ve seen unprecedented outbreaks of infectious disease along Syria’s border with Turkey? That’s not a good idea.

My hunch is that general fatigue and a mismatch between maternal waking hours and clinic hours might be the major inhibitors, but I’m open to other ideas (someone just told me some people view vaccination as breaking fast). No moms want to wait in line for hours in the early morning after preparing food all night. Nobody wants to do anything at 3 p.m. after nine hours without food or water. I barely drag myself to 8 am classes on normal days and definitely cannot without scary volumes of espresso, so I feel like these things aren’t unreasonable. One specific goal is to channel these findings into specific policy recommendations on clinic hours, which could be a good work-around.

2. Expand UNRWA’s mobile health capacity. We’ll be issuing immunization prompts to more clinics – hopefully some outside of Jordan, and some catering to Palestinian-Syrian double-refugees! – and gathering some hard data on effectiveness and patient satisfaction. Beyond that? The specifics are still up in the air. One promising suggestion from last summer involved sending reminders on basic aspects of diabetes management to adult patients. I’m not a huge fan of basic mobile health initiatives like this (engineers are technology snobs), but I do think they can be especially useful for patients with limited mobility. Gaza New Camp, in Jerash, provides a good (well, awful) example. The ’67 refugees who live in the camp were not afforded Jordanian citizenship, so they can’t obtain licenses or buy cars; if they bought motorcycles instead, however, they’d be short-changing the Jordanian economy by investing in a cheaper mode of transportation, so they’re also not allowed to buy motorcycles (cue eyeroll). So, if you live there, and your diabetes symptoms progress beyond anything you can manage, good luck getting to your regular dialysis treatments.

Of course, it’s not a problem if for Jordanians who reside in Abdoun mansions – take either of your Porsches down to King Hussein. But that kind of extreme disparity is what allows global health issues in the Middle East to fly under the radar: everything averages out to Middle Income Yellow (new Crayola shade?) and funding is directed elsewhere. Bigger rant on this later.

3. Health care as a bargaining chip. This is an iffy one, perhaps best illustrated by Hezbollah. They provide medical care that drastically undercuts the going rate on Lebanon’s private market, and care is FREE for Hezbollah party members. If you’re poor and sick and on the fence, is that opportunity enough to sway your political stance? There’s rumor of similar models being tested by different extremist groups in Mali, and I’m worried that this might be a growing phenomenon as AQIM spreads southward throughout and across the Sahel to sicker and more impoverished lands.

To be fair, one could argue that USAID does the same thing, “From the American People” emblems and all – maybe that would make a nice proxy study. I’m not sure exactly of how to pursue this line of investigation, but I think it’s really important and I’m surprised it isn’t getting more attention. Tentatively, I’d like to head up to Zaatari, where UNRWA is trying to deal with lots of pharmaceutical theft & redistribution, to see if there are any grander motivations aside from making a buck on the UN’s dime. Maybe I’ll gather up the gumption for more casual interviews in Beirut. More broadly, if there is any real political shift that comes from this discounted care, I’d like to see it incorporated as a very low-cost national security strategy. The US is good at fighting fire with bigger fires, but fighting knockoff pharmaceuticals and pandering with effective, strategic, and heartfelt health investments seems like a much better deal to me.

Amman: Round Two

UNESCO. Too long for the Twitterz.

At lunch with Arthur Lenk yesterday (thanks, Baker Institute!), someone inquired how he (Israel) felt about the US pulling their (22% cut of) UNESCO funding after Palestine was admitted as a full member nation . He brought up the obvious valid point – what happens when bids to other multinational organizations succeed, and when we “have” to cut funding to, say, the World Health Organization – and then proceeded to scold voting parties for not considering the result of cutting US funding.

Are you kidding me? That’s the problem? That other member states care less about international research or cultural preservation or AIDS treatment or global vaccinations than acknowledging statehood? Absolutely not. It’s a huge and conscious “fuck you” to hypocritical, contradictory US policy. No better way to do that than to call a bluff.

(Al Jazeera)

UNESCO. Too long for the Twitterz.

Shots in the Dark

When it comes to a Sophie’s Choice sort of prioritizing, I tend to value national security over minor setbacks in other fields. This is not a popular sentiment in the field of public health, where evangelists are evangelists and the US government is a happy target frequently accused of, god forbid, acting on its own interests. In terms of bulk cost calculations – why spend billions on aircraft carriers when that same money could go to treating malaria? – I also think that Givewell types tend to undervalue hegemonic stability and underestimate, or have perhaps forgotten, the dangerous down stream flailings of a wounded giant. I am One of Those Democrats, and I’m not sorry for it.

But foreign aid, and particularly well-designed health assistance, is in the interest of national security. Unrest results from lack of satisfaction with the state of affairs; extreme dissent emerges in hungry, impoverished, and desperately ill populations where people have the balls to get angry (that is to say, in a less crude manner, societies where women possess limited rights – but that’s another post). And here are a few True Things:
1. Maintaining public health programs abroad is a critical part of the ability of the United States to influence policy abroad in a subtle, effective, and generous way.
2. Vaccination is unparalleled as far as things in our toolbox go. They save money – something entirely uncommon in international aid. This may sound very simple, but it’s extraordinary: a successful vaccination program allows us to prevent lengthy courses of treatment for expensive diseases in difficult-to-access areas.
3. The vaccination “scandals” in the US – such as Andrew Wakefield’s ridiculous shenanigans – have resulted in an inexplicable amount of damage. Accusations of vaccines causing autism in a nation where most people are literate, where 70% graduate from high school after completing a basic biology courses, have been crippling: as an example, one of the most conservative governors in the nation was bullied into not mandating a Gardasil vaccine. The amount of damage associated with something most people don’t understand is amplified as the education of the general population plummets. So when a rumor starts up that US vaccines are intended to render Muslim children infertile in Nigeria? People believe it, and consequently have their children die from preventable diseases.

In attempting to use DNA samples obtained from needles to confirm Osama Bin Laden’s presence in the compound, we did not give the Pakistani children in Abottabad the full 3 courses of the hepatitis B vaccine necessary to ensure functionality. Those kids are not going to have access to the full course – and if they do, why should they trust it?! Why on earth should they, when a legitimate ruse has been constructed against them in which vaccination was hardly considered a fringe benefit? I don’t see what this should have to do with the political sympathies of the children involved, or of their parents; when the United States lies abroad, when we conduct ineffective schemes in places where our word is already compromised, we make enemies. When we do a good thing poorly, we make enemies. Let’s stop doing that right now.

Shots in the Dark