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John Harvard's Journal

Think Tank for Aid Workers

November-December 2007

After Michael J. VanRooyen finished his residency in emergency medicine in 1991, he went to Somalia. Eager to see how his medical training would translate into the context of a poor nation torn by civil war, VanRooyen concluded very quickly that it didn’t. His training had focused on maladies a doctor would expect to encounter in the developed world; instead he was dealing with malnourishment and malaria. During the next decade, he traveled to some of the world’s most dangerous and disaster-riven places: Sudan, Bosnia, Rwanda, Croatia, North Korea, Haiti. Those experiences convinced him that the field of humanitarian aid is “150 years behind medicine” in terms of evaluating need and using evidence-based practices to respond.

VanRooyen is now assistant professor of medicine at Harvard Medical School (HMS) and an associate professor in the department of population and international health at the Harvard School of Public Health (HSPH). He arrived from Johns Hopkins in 2004 to work with Jennifer Leaning, associate professor of medicine at HMS and professor of the practice of international health at HSPH. She, too, has copious field experience—in Afghanistan, Albania, Angola, Kosovo, Somalia, and Darfur, among other places—and also saw opportunities for greater efficiency. Too often in humanitarian work, Leaning says, “the din of work drives out creative thinking and strategic planning.”

In 2005, Leaning and VanRooyen founded the Harvard Humanitarian Initiative (HHI) as a place where such thinking and planning could occur. An interdisciplinary center with affiliated faculty from Harvard’s schools of law, government, and business, as well as medicine and public health, HHI brought leaders from major humanitarian organizations to Cambridge in September for the second annual Humanitarian Health Conference. In all, 123 representatives from 68 organizations—including UNICEF, the office of the UN High Commissioner for Refugees, the International Committee of the Red Cross, Oxfam America, the U.S. Agency for International Development, the World Bank, Catholic Relief Services, and Mercy Corps—attended.

Much of this year’s conference focused on the need for better, more rigorously gathered data from crisis zones. As an example of the impact such data might have, VanRooyen points to results in the Democratic Republic of Congo, which has been embroiled in civil war since 1996. A randomized mortality survey, conducted by the International Rescue Committee (IRC) in 2000, found that the war and its byproducts—crippled infrastructure, food shortages, and the like—had caused 2.8 million deaths. The findings dwarfed previous estimates, which had been in the low six figures, and prompted a drastic increase in aid to the conflict area. (The war continues, and the last IRC survey, in 2006, put the death toll at 3.9 million.)

Although a scientific, statistical approach has proven instructive in other contexts, as well (see “Counting the War Dead,” opposite), by and large, says VanRooyen, “we operate anecdotally.”

Obtaining copious data also carries a hazard: workers in the field can spend all their time gathering information, rather than helping people. Leaning warns that monitoring organizations need to be ruthless in identifying the minimum data needed to evaluate a program; asking about the incidence of water-borne diseases would be essential in Bangladesh, for example, but a waste of time in Ethiopia, where drought is a more likely cause of malnutrition and death. “There are somewhere on the order of five to 10—maybe, if you really push it, 15—global health indicators that need to be gathered all the time,” Leaning says. “Now we need to figure out what they are.” (Working groups at both HHI annual conferences have considered how to define this list and coordinate data collection.)

Meanwhile, HHI is taking a leading role in one of the proposals from last year’s conference: creating a consortium of humanitarian organizations that share information to avoid duplicating each other’s efforts or repeating each other’s mistakes. (As the final conference paper put it: “Instead of having 20 years of experience, we have one year of experience 20 times.”) Proposals included a Web-based forum and a 24-hour telephone hotline offering technical support.

On another front crucial for the field’s future, human-resource development, HHI has already seen results. HMS has begun to offer a certificate in humanitarian studies as an option for medical residents. HHI itself offers training programs for active-duty humanitarian-aid workers and human-rights investigators, and hopes to draw on the Business School’s expertise in executive education to create programs that train field workers to become managers in their organizations.

What’s needed to develop the next generation of humanitarian workers, professionals agree, is an established course of study with a standardized, clearly defined set of requirements. HHI already provides support for one program along these lines: the Humanitarian Studies Initiative, a joint graduate program of HSPH, MIT, and Tufts University’s Friedman School of Nutrition Science and Fletcher School of Law and Diplomacy. With humanitarian-aid tracks at all medical schools—and even, perhaps, at the undergraduate level—humanitarian workers of the future would not have to feel as unprepared as VanRooyen did upon landing in Somalia.

The need for coordination and strategic planning is so great because the field has changed so rapidly in the last 15 years, VanRooyen says. Aid had been used as a political tool and limited by political concerns, but with the Cold War over and the world no longer divided into spheres of influence, the field of humanitarian aid blew wide open. Almost overnight, organizations gained unprecedented access to formerly inaccessible regions. There was little coordination among them, and almost no control over how they operated. The prevailing logic was that delivering some aid—even if it failed to meet needs fully, or the people delivering it lacked experience and training—was better than doing nothing. But, says VanRooyen, “Sometimes it’s actually worse than nothing.” He gives the example of how a cholera epidemic swept refugee camps in Zaire in 1994, killing 30,000 people who had fled genocide in Rwanda only to die in the place that was supposed to keep them safe.

One outgrowth of such unintended consequences is the Sphere Project, a set of minimum standards for humanitarian-aid operations first issued in 1997 and most recently revised in 2004. But because compliance is optional, minimum standards have become another area of interest for HHI.

Though some may voice frustration at the slow pace of change, Leaning draws a parallel to the field of public health. “It’s taken decades,” she says, for the Centers for Disease Control “to come up with its routine measures of what it’s watching over the years. It’s a really hard problem.”