Uzma Alam on Community Engagement in International Humanitarian Health
How can community engagement and design help humanitarian health workers save more lives? What can the humanitarian health community learn from global brands like Coca Cola and McDonalds?
In this episode of FoossaPod, we hear from Dr. Uzma Alam, an expert in international humanitarian health and an Allies Reaching for Community Health Equity (ARCHE) Public Voices fellow with The OpEd Project and the Center for Global Policy Solutions.
Uzma Alam (left), Michael Seo, and Pierre Evens Jean-Louis review health data at Klink Fonfrèd, Haiti
How do you design programs, hospital programs? How do you think of vaccination? It’s all a design question, and it’s a very interrelated topic. It’s one that we need to challenge our assumptions on. As a community, we need to start thinking forward. How do we design better? How do we think through it? It’s with the people. They understand their context better than we can ever. They understand what the problem is. They understand the need, and they have the capacity. — Dr. Uzma Alam
Podcast music: "Daybreak" by Baja Snake (Remixed by Hepnova) and Rwandan field recording #3 by Lee-Sean Huang
The following is a transcript of Lee-Sean's conversation with Dr. Alam. We have made minor edits and added emphasis to the transcript for the sake of clarity and readability.
Define “Humanitarian Health”
Dr. Uzma Alam (UA): My name is Uzma Alam, and I am a global health professional specifically working within the humanitarian sphere.
“The humanitarian sphere” refers to any work related to providing humanitarian aid.
“Humanitarian response” refers to addressing the needs of refugees and internally displaced people. Or further, within the health system, humanitarian response can also refer to addressing health crises such as Ebola.
Lee-Sean Huang (LS): In terms of a humanitarian crisis, that could be everything from a natural disaster such as a hurricane, an earthquake, a flood, or something that’s man-made: armed conflict or civil unrest.
An outbreak of an epidemic is kind of a combination of the two. It’s a combination of human behaviors and natural phenomenon: pathogens, germs, diseases that spread in a population and start to go out of control.
UA: You defined it better than I could have.
[Laughter]
“Are we actually going to save more lives?”
UA: I have a unique background in research that allows me to put on both hats as somebody to work on the ground, but also as somebody to work within policy.
Within the humanitarian communities, there’s this growing recognition that we need to start engaging with knowledge management and learning. One of the ways in which that can be understood is through operational research
How do we start thinking about how to provide better responses? How do we start thinking about the long-term implications of what we do? How do we start thinking about what we can apply from one disease outbreak to another?
But then also translating that knowledge into a more sustainable, long-term impact, which is where the policy piece comes in. How can we use more data-driven evidence to align policies to the needs of communities that we are serving?
LS: In terms of learning, especially in humanitarian response, where there is already a crisis, some sort of emergency, something has already gone wrong and you are trying to make it better.
So politically it’s really difficult, because I think people doing humanitarian work are criticized when things go wrong or they get worse in these situations that are already quite challenging to work in.
A lot of these methods in the innovation space of “failing fast” and “failing forward” and being iterative and agile, they don’t fully apply in a humanitarian context when people’s lives are literally on the line, or when these situations are already very difficult.
How do you learn and experiment and allow space for that learning in these situations that are quite often literally life or death?
UA: There are two ways of thinking about that: you very rightfully said that people’s lives are at risk. You need to respond, and yes, as first responders, as people guided by the humanitarian principles of saving lives, there is this basic response to go in and provide aid — the very basic needs.
But beyond that, as a community, we need to start challenging ourselves. What happens when we take the time to take a step back and think things through, rather than just responding?
Are we actually going to save more lives? Or are we just doing things the old-fashioned way because that is how we have been programmed?
I think that’s where the mindset needs to come in, and that’s what’s going to actually lead us to what we need to do and save more lives.
There’s this whole concept of “it’s an emergency, we need to do A-B-C-D,” but the reality on the ground is very different. A crisis in Somalia is not necessarily the same as a crisis in Yemen. Right?
LS: Sure.
UA: That’s where Design Thinking comes into it. That’s where community engagement comes into it. That’s where the whole concept of saving lives needs to be expanded and thought through.
We can’t just say that if we just provide water in a certain way, we are doing what needs to be done. That’s not how it’s working. Especially now.
We have all heard in the news and social media: there’s a refugee crisis. There’s the biggest humanitarian crisis going on. Every single day, 45 thousand people are displaced from their homes.
Unfortunately, with global warming and with political conflicts, these crises are just going to grow in number.
Humanitarian communities are already overwhelmed. Just look at the Horn of Africa: for the very first time in forty years, the humanitarian communities are dealing with famine across three different countries at one single time.
On the flip side, as we all know, there’s a lot of politically-charged debate when it comes to immigration issues, when it comes to funding, when it comes to donors.
So how do we combine our principles of trying to save the most lives and reconcile it with not only increased volume of crises but also prolonged crises? That’s the state where the humanitarian community is at now.
“Engage with a community to design for their needs”
UA: In my opinion, the solution to this is actually community engagement: engaging with a community to design for their needs, to understand the culture, to go in not only as humanitarian workers, but to go in as brothers, sisters, fathers, mothers of the community.
Because for the people at the crisis, there is one thing that binds them together: their culture. And if we don’t understand this, and we don’t engage them, whatever we provide is not going to be sustainable. It’s not going to be the right response. And at the end of the day, it’s not going to save lives.
So it’s not going to do anything that we actually want to achieve.
How do you deal with people with disabilities who are refugees? We usually have pit latrines and stuff, but how is this accessible to people with disabilities?
How do you design campsites for cultures that separate men and women? How do you design programs, hospital programs? How do you think of vaccinations? It’s all a design question, and it’s a very interrelated topic, but it’s one that we need to challenge our assumptions on. As a community we need to start thinking forward.
How do we address these questions? How do we design better? How do we think through it?
The answer is: it’s with the people. They understand the context better than we can ever. They understand what their problem is. They understand the need. And they have the capacity.
It’s the crisis of the experts. We are the “experts.” But we’re not. That’s not the case.
LS: So when I hear the words “community engagement,” this term being mentioned in a humanitarian context, I think that these are people who are already very vulnerable. They have escaped from armed conflict, or they are fleeing some epidemic or natural disaster.
How do you engage them? Because it’s challenging enough in a non-emergency context, whether it’s knocking on doors, or trying to talk to strangers in a neighborhood here in New York City, but when people are in a refugee camp or just fleeing from something…Clearly we know that aid can’t be a one-way, unidirectional kind of thing. Right? But at the same time, how do we engage people who are already vulnerable? Maybe some examples will help?
UA: You have rightfully pointed out some of the difficulty, or the presumed difficulty around community engagement.
But saying that something is difficult doesn’t mean that it cannot be done. And more importantly, by thinking that way we refuse making progress in what can be done.
I think we have reasons to make change. We’ve talked about the statistics: how the refugee crisis is increasing and how the humanitarian community is overwhelmed, about the policy implications and the donor implications, and how something needs to change.
Our thinking needs to change about how we respond and how we provide services better.
“Yes, it’s an emergency, but we still have time to think”
UA: We are in a time where, as a humanitarian community, we’ve got a lot of innovation. We’ve got a lot of technologies, so there is a time where we can actually take advantage of this and start thinking about how to engage communities.
There are lots of difficulties, but there are also lots of opportunities, and it’s a matter of us looking for them.
And another thing that I think is really important to remember is that longitudinally, across all the crises, very few of them, about one percent, are truly life-saving emergencies in that we have to act then and there in the moment. These are usually in the context of conflict. But in cases of epidemic, in cases of floods, in cases of natural disasters, yes, it’s an emergency, but we still have time to think.
When we start thinking of design and community engagement, there are multiple levels to it:
We have a lot of access to news, to social media, to big data, so it doesn’t mean that I as a first responder, or I as a humanitarian aid worker or as a policy person cannot familiarize myself with that community. So there are tools.
There is this piece that we have already that needs to be used. We need to get smarter about how do we think of data, how do we understand the context, and how do we understand the culture.
And then beyond that, once you’ve provided your basic needs: you’ve provided the shelter, you’ve moved people out of harm’s way, you’ve provided them food, you’ve provided them with water, whatever their needs are, which are the standard basic needs…
You have to remember that these conflicts are getting longer and longer and longer. Look at the refugee camp in Dadaab, it’s the biggest refugee camp in the world. It’s been more than 20-some years. It’s not right of us to say there was no time to engage with the community.
Lessons from Ebola
UA: One of the biggest lessons from Ebola was how it was not necessarily a public health failure, but it was a failure of us recognizing the capacities of the communities on the ground, understanding their practices, understanding their communities.
The data was very clear from Ebola: once we got the communities involved, that’s when the tide of the epidemic started changing.
Ebola is transmitted by bodily contact, and one of the big moments, the highly infectious moment, is when dealing with dead bodies. And within West Africa there was this practice of washing dead bodies or providing last rites — different sorts of cultural beliefs that had very intimate touch between families and their diseased.
One way that we, the humanitarian community, tried to prevent that was to say, “you aren’t allowed to touch the dead bodies, we are going to come and take them and bury them.” And there was this huge resistance. Communities wouldn’t call in and tell us that they had lost a loved one for obvious reasons. They didn’t want a foreigner to come in…
LS: So you created a new stigma or taboo.
UA: Right, they just didn’t want to not be able to perform their last rites.
And then, we got the interfaith organizations involved. We got the interfaith communities involved. The imams and the priests and everybody got together, and they actually pulled out messages from the Scriptures, from the Koran, and from the Biblical texts, which they took to the communities to say, “this is how you deal with dead bodies: bury them immediately, don’t keep them; it’s about respect and stuff.”
And that’s when people started understanding the message. We were talking in one language. We were talking in this public health perspective, “oh! it’s infectious and stuff.” And that wasn’t the issue for the people. For the people, the issue was, “look, if you can’t prevent it…”
I’ll give you this direct quote. I still remember it. Somebody said to me in Sierra Leone, while I was on the ground:
If you can’t show me how to stop getting Ebola, or if you can’t cure me, why are you teaching me how to bury my dead? I’ve been doing it for years. We’ve been here for centuries.
LS: It’s almost this crisis of expertise. What are you even doing there as a humanitarian relief worker?
UA: Exactly! Right? We just didn’t understand the communities.
I can go on and on with the Ebola example. There were examples around quarantine…
There were examples of messages about “don’t eat bushmeat.” There were communities that had never eaten bushmeat, and yet they had Ebola. So these messages didn’t make sense to them. And we didn’t think to engage with them and to try to understand the culture and what it meant.
So this was our failure. We were trying to respond in a scientific manner, in a public health manner, in a vacuum, without understanding our context.
The only way to do it is if you actually talk to the people who have actually got the problem. They have the solutions. They are the closest. We are just meant to be there as a bridge.
As an organization, we failed that.
What humanitarians can learn from Coca Cola and McDonalds
LS: It sounds like it’s a matter of, one, understanding the context and that the communities understand their context better than outsiders, for obvious reasons.
In the example you gave of the bushmeat, if this particular community had never eaten bushmeat, it sounds like you were trying to impose this one-size-fits-all solution on that community.
I think that in the private sector, brands have understood this for a long time. Take Coca Cola or McDonalds for an example. I know this is a slightly strange comparison and parallel between Coca Cola and McDonalds, which are ubiquitous around the world, and humanitarian aid situations.
But if we forgive this for a moment and go with it, you know that McDonalds is more or less the same anywhere you go, and so is Coca Cola. But they do adapt the branding and the formulation and all of these things no matter where they go.
UA: Exactly.
LS: Coca Cola means something different in the US context, where it’s been around for a certain amount of time. It might be stigmatized in certain communities, whereas in China, or some developing country, it means something else: it’s a dependable, safe drink to have, or it’s an aspirational thing, or whatever. It means something different.
Even these aspirationally universal brands understand the importance of localization. So how do we apply some of these principles of localization and local understanding to humanitarian contexts? Because no two humanitarian crises are the same.
UA: Beyond this, we need to ask, “what is the direct impact of this?” How does this actually get results versus what we have just been doing. I think this should be at the heart of all of the discussions that we are having.
When we start engaging people, when we start understanding context, we are actually empowering people to do what they need to do.
So automatically, we have started this circle of change, which is empowering, which is what we need. But how do we localize this? How do we make it possible?
I think this is, again, a very politically-loaded question but very timely. I think here comes into the interplay of how international NGOs interact with local governments or with local NGOs. How do we start engaging with them?
How do we exchange capacity? Everybody’s got a capacity. So how do we engage with the capacities that are only on the ground, beyond other NGOs, beyond engaging with the government?
So why wouldn’t we engage with them? Why wouldn’t we work through them as a conduit to get where we want?
Those are the questions that need to be addressed when it comes to localization, but beyond that, it’s not just NGOs. I talked to you about Ebola because it was one of the most recent crises. Syria and Yemen are other examples. It’s not just about NGOs.
A lot of these communities have faith-based organizations. A lot of West Africa is in the Muslim community. How do we engage with the imams? How do we engage with the priests? How do we engage with women leaders?
That’s how I picture localization. It’s about relationships. It’s about building partnerships. It’s about going in to help, not to control.
The Role of Donors: Localize Capacity
UA: The other part to localization is obvious: the big role of donors. You cannot just go in and start building relationships. This is something that needs to be sustained.
But then also donors need to start understanding that the distribution of funds, if it’s going to have an impact, cannot just be a top-to-bottom approach. It needs to be localized. The way we distribute our funds needs to be localized.
We need to put that concept into place, that we need to work with local players. We need to provide the funding to local players. We need to provide this capacity to local players to start responding. Because, you know, in all reality, they’re the first ones there, before an international person gets in, or before an international NGO gets there.
It’s the local NGOs and the local governments and the local communities that are already responding to their needs. But they are just getting overwhelmed. And if we don’t build the system right, then we already setting ourselves up for failure.
That’s how I think of localization:
Partnerships, which is relationships, which is the human piece, and it takes time; and obviously
Capacity, a big piece of which is the
Funding.
LS: On the idea of relationships, one way to reconceptualize, to reframe that, is to think of the existing social and community infrastructures, that network of relationships in a given community or group.
Think of this network as an existing asset or resource. Just as if you were going to be helping with physical infrastructure development, you would look to see whether there is already an existing source of fresh water. Then you don’t have to truck water in.
Or if there are sources of building materials in terms of wood or stones that you could use, then you wouldn’t need to ship in building materials.
We understand this in terms of physical resources, but we also have to think of these social resources that already exist when we go in. And of course we can build on them and shift them. But you are not starting from zero.
Rethinking Metrics and Measurement
LS: My other reaction to that is also thinking about the metrics and the way that humanitarian aid is being measured. On one hand, there is almost this tyranny of what’s easily measurable, versus things that are harder to measure but just as important.
It’s probably relatively easy to measure how many patients you have seen or how much medicine you have dispensed in an Ebola outbreak situation.
But then there are things like behavior change that are just as important to stopping an epidemic like that, but are much harder to track. But they are important, and that behavior change involves community engagement.
Whether it’s using community thought leaders or influencers, through religious leaders or other forms of social networks, that sort of thing is much harder to track and to keep tabs on.
UA: Measurements are a great thing. We all know that. But it doesn’t necessarily mean that everything that we measure has a meaning or is good.
Especially in this context, if we don’t have good baselines, if we haven’t thought of needs, if we haven’t thought of capacities and stuff. That raises the question: what are we truly measuring and why?
You have already pointed to that, that it might just be an artifact of how funding works, unfortunately.
But, going beyond that, it goes back to how we started the conversation where I pointed out that the humanitarian community is waking up and realizing that we need learning, and we need knowledge management. We need to start rethinking how we respond.
One of the newer debates, one of the ongoing trends between this whole area of work is that there is a fine line between humanitarian response and international development, especially with this whole prolonged crisis.
In a development context, measurements, taking metrics, is more of a norm.
So again, it comes to the question of: if it’s not done right now, does it mean that we don’t need to do it? Or is there a way of doing it?
You should measure whatever you can, and you should make measurable what you cannot.
There’s power in data. There’s power in evidence. Especially if we want to start thinking about what we talked about earlier: how do we start changing policies? How do we start having long-term impact? How do we start having influence?
Yes, donors for us to measure certain things, but we need to question: are we measuring the right stuff? And how do we use these measurements?
Humanitarian Data: Opportunities and Responsibilities
LS: On the tools of measurement, I think that with technological advances, there is also a faster feedback loop to figuring out the right way to deploy those technologies, whether it’s through mobile devices, or the Internet of Things, or even social media.
People in these humanitarian crises often still have cell phones that still work. Can they be creating their own data or inputting their own data as a form of feedback? Or can humanitarian workers be collecting data through mobile devices?
All of these things shorten the feedback loops in ways that help us learn. But it’s still this challenge of what kind of data should be collected, and what kind of data is actually helpful in these situations?
UA: For sure. There’s no doubt that technology and innovation is going to be playing a big role. But I think we need to take caution here and understand that some of the information that we collect comes with ethical implications. And we could be putting the very communities that we are out there to protect at risk.
LS: Sure.
UA: And I think that’s something that makes the use of innovation something that can’t just be instantly deployed. There are lots of cases where we could think of how somebody’s data could negatively impact actually saving their lives, which is the crux of the humanitarian principle — basically, saving lives.
I think it’s a dual-edged sword, but something that needs to be thought of. Obviously, the community is engaging in it. I know there are lots of discussions going on. I know academics and different organizations at the forefront of thinking about this:
What does humanitarian data mean? How do you collect humanitarian data ethically? How do you protect this data?
And also, a lot of the populations that we serve are migratory. So how do you share this data with them? These are all very important questions.
LS: With this new innovation comes this new responsibility. Then data security becomes this new competency that’s necessary in humanitarian response, if we are going to be collecting all of this data through electronic means.
UA: Yes, exactly. And who does all that data belong to?
If a government comes down and asks us for the records of how many people of an ethnic background we’ve treated, and we know that these people are already at risk of persecution, right? Then what is our responsibility?
Is this data worth collecting? Do we need it?
LS: Right, and it’s sometimes safer not to ask certain questions.
UA: Yes.
“It’s the job of every human being”
UA: The question that you started asking, what does “humanitarian” mean and what does it define: I think it’s everybody’s duty and responsibility.
It’s not just people working directly in the field, it’s everybody: design thinkers, data collectors, innovators, entrepreneurs, people engaged in civic engagement, our policies.
Politics. Just us being human beings, to engage with our governments, who actually form policies that influence somebody’s life across the world.
Our social responsibility as somebody who understands something, is to stand up for the people who are most vulnerable and at need.
If there is one message that I would like to put out there, I really appreciate people empowering themselves with the knowledge, with understanding: What does it mean to be a refugee? What does it mean to respond? How does a humanitarian response work and how to engage with that?
It’s not just the job of international NGOs. It’s the job of every human being, as a human being knowing that there is somebody suffering at some point in the world. There’s a life to be saved.
You can empower that. You can touch a life. You can change that one life. And that counts.
LS: Thank you so much Uzma.
UA: Thank you.