When humanitarian catastrophes erupt around the world, it can be easy to feel overwhelmed by the scale of suffering. How do aid workers navigate the immense challenges in order to jump into action—juggling safety, equipment and logistics? Emergency doctors Craig Spencer and Adam Levine, veterans of public health disasters across the globe, join host Megan Hall to explain how this kind of aid works, and to demystify the humanitarian response in Gaza today. 

Welcome to Humans in Public Health. I'm Megan Hall.

In the past few years, the field of public health has become more visible than ever before, but it's always played a crucial role in our daily lives. Each month we talk to people who make this work possible. Today, Doctors Adam Levine and Craig Spencer.

Craig and Adam are both experts in emergency medicine. They’ve treated patients and organized logistics for humanitarian aid missions all over the world.

I was working in Burundi

in South Sudan

Eastern Chad

in Liberia, in Haiti

On a boat In the Mediterranean many times

in Libya, and in Bangladesh

In the news today, we’re hearing a lot about another part of the world: Gaza. Here’s Craig:

We can have disagreements about the, you know, the politics or the justification for the use of arms in this conflict but it's undeniable that there's a massive public health and humanitarian crisis in Gaza

Since the war between Israel and Hamas started, 24 thousand Palestinians have been killed. Nearly 2 million people have been displaced. And the UN says the region is on the verge of a famine.

We know that two thirds of all hospitals and clinics have been destroyed. And for those that remain, they're working without the most basic essentials, not just supplies, but you know, even running water.

So, we invited Craig and Adam to explain how humanitarian aid works, and to demystify the humanitarian response in Gaza.

Although Adam and Craig haven’t worked in this part of the world, they’ve both worked in conflict zones before, and Adam is in touch with some of the groups that are there right now.

So based on your experience, I’d just love to know how you respond to those situations, starting with when you come to a country that's facing a conflict, it's total chaos, I'd imagine. Where do you even begin? How do you start?

I think you can start with a question of who's coming into that country to help, because in a lot of conflicts, it's no one or it's very few organizations. As with all crises around the world, the majority, especially early on, the majority of the response comes from local people and from local communities, local healthcare providers. And our goal as outsiders should be to support them in any possible way that we can. And I've worked in conflict, where there were very few other organizations that were there, because when things get scary groups get up and leave as well. It may not just be humanitarian groups, there are also groups working in countries that are doing development that are working on a whole host of other programs to support populations and communities, who don't have much of an appetite or don't have the security protocols to stay in the country.

So what do you do when you're starting from square one, and you don't have partners?

Well, sometimes you're starting from even further back than square one, you have to think about how you get logistics into the country, you have to think about how you get visas, whether you can get visas.

We had a lot of difficulty negotiating with the Burundian government at that time about getting visas because they saw us as supporting the rebel group, we were providing health care to anyone and everyone. And by being neutral by providing health care to both, we were giving health care to what was seen as their enemies. But at the same time, someone had gone into the local trauma hospital, and had unfortunately killed many of the surgeons and the anesthesiologist. So there wasn't any other trauma care in town; we were it.

So it sounds like when you're coming into these settings, it's not enough just to be a medical expert, you also have to have political negotiation skills on top of all of that?

You need medical experts, sure, but I can't do anything, I can't put in a chest tube, if I don't have chest tubes. I can't, you know, reliably triage hundreds of people, if I don't have structures, or other personnel that can speak to these folks in their local language, to make sure that the symptoms I see are exactly what's happening with them, I can't do any of that, if we don't have a logistical team to get those things.

Everyone thinks about the frontline doctor, but that is just a tiny piece of it. And on a daily basis, the number of people who need medical care is always going to be very small, but the number of people who need to eat is going to be huge: everybody. The number of people who need to have a safe place to poop is going to be huge: everybody. And so that means that, you need to have all of the diversity of skill sets, not just doctors, but also engineers, epidemiologists, you need to have people who know how to negotiate with different types of actors, as the case may be.

When Adam was working in Libya during the Civil War, those negotiations were even trickier.

We had to negotiate with multiple different actors in order to be able to ensure that our trauma field hospital was not destroyed. You know, there was the army of Qaddafi, which itself had, you know, large numbers of mercenaries coming from other countries, there was the rebel militias. And that wasn't just one militia like, it was dozens and dozens of different militias that had to be negotiated with each with their own leadership. And we had to make sure that we didn't get bombed by NATO either. So we were communicating with all of these different forces, and it was, you know, very high intensity during that time.

It’s getting even harder for large scale humanitarian aid groups to stay safe.In Gaza, the UN’s Relief and Works Agency, has seen more than 130 of its workers killed. Craig says it’s part of an alarming trend.

But what we've seen, especially over the past 10 years, starting in Syria, more so in Ukraine, and now in Gaza, is that there has been a targeted attack on healthcare institutions. This not only has that kind of one off horrible impact of losing lives and losing structures. But it takes a really, really long time to rebuild healthcare infrastructure. It takes, you know, a decade to train a doctor, it takes years to train a nurse or other folks. And it takes a long time and a lot of money and safety to rebuild healthcare institutions.

In Gaza, Craig says a lack of health care services could eventually cause more damage than the war.

It is, as we've seen in so many other circumstances, only a matter of time before we get things like measles outbreaks, which would be so so much harder to respond to, to contain, if we don't have humanitarians in place that are both provided with the logistical support that they needed, but also the safety that's required to do that work.

And the lack of food will affect Palestinian children long after the war

We've seen this after the crisis in Biafra in the 1960s. We've seen this in World War Two with populations in the Netherlands who had even just short periods of famine and not enough food. It has lifelong consequences in the likelihood of getting diabetes and hypertension, so the crisis and the public health impacts are massive now. But even if this were to end tomorrow, the implications can go on for quite some time.

With all of these different political polls, humanitarian aid is supposed to be apolitical, it's supposed to be neutral. But is that possible?

In reality, it's really hard to live up to those different precepts, even though all humanitarian organizations, at least all big ones, subscribe to them.

You know, number one, independence, well, 90% of humanitarian funding comes from donor governments. The United States, the European Union, in some cases, Japan and China and the Middle East. And so these governments that are giving funding to these organizations also have military and political objectives. And even if they're not a party to the conflict, they're probably an ally with somebody who's a party to the conflict. So it makes it difficult for the organizations to be truly independent, because they can't even go to a place if they don't get funding from the donor government to let them go.

And Adam says sometimes, being impartial just feels wrong.

humanitarian organizations, you know, are filled with people, and they're seeing suffering, and they're seeing horrible things. And in some cases, especially when the media is not there, they are the only source of information for the outside world. And so there is this desire to actually make known the horrible atrocities that are going on, so that maybe somebody somewhere in a capital can actually do something about pressuring the, you know, groups committing those atrocities to stop. And so that is the tension that many organizations will face. And if they do speak up, there's the risk that they're going to get kicked out and then not be able to provide that humanitarian assistance to those who need it.

It's really, really hard. But it's good to have guiding lights. I have worked primarily with Doctors Without Borders. And we are an organization that thinks all of those principles are incredibly important.

Craig says Doctors without Borders also believes you can’t sit idly by while you’re being neutral — that you have to speak out. The organization used this principle during Craig’s time in Burundi.

What we would see is that a disproportionate amount of the injuries were amongst this group that was fighting the government. The government had way, way more tools, way more weapons, way more grenades. And so we as an organization had to think about like, we're going to be neutral, we're going to take care of people on both sides, we're not going to be part of this conflict. And at what point do we say something? What do we do? And as Adam pointed out, we knew that as soon as we said something, wrote something in the press, we'd be booted out of the country.

In Gaza, Doctors Without Borders decided to be vocal about what they’ve seen. They’ve made statements calling for a ceasefire.

But for workers on the ground, humanitarian work is often less about the big picture and more about minutia, like handling supplies.

Craig and Adam have seen some interesting attempts to help humanitarian aid work- in Haiti after the earthquake, they saw people send items like a single roller blade or a crate of stuffed animals

Even some medical supplies sent to Haiti caused problems.

We had this giant storeroom full of medications that have been donated from all over the world. And going there to find what you needed was like, you know, an afternoon’s work. And I remember, every time I went in there, I had to go around this giant pallet of boxes. And one day, I was like, gonna figure out what was in this pallet of boxes. And I, you know, looked at the labeling and didn't recognize the name of the drug. And then later, when I had internet, I looked it up, and I realized it was a prostate cancer drug that had been sent. And I was like, Why did they send this?’ and then I looked and saw that it was just about to expire, and I realized, oh, so some drug company got, you know, some sort of charitable donation and tax exemption from sending this pallet of boxes that has been, you know, preventing me from getting the medicines I need to people for the last month.

Even experts can make the situation worse. U.N. peacekeepers in Haiti caused the country’s devastating cholera outbreak after their wastewater contaminated a river.

Adam’s research has looked at ways to professionalize humanitarian aid. So mistakes like these don’t happen. When he started working in the field…

You know, you sort of were thrown into it and expected to learn as you went along. And that got me interested in thinking about how we could change that, and how we could actually build an evidence base for humanitarian response, even in these difficult conflict and disaster zones, so that we could be sure that the good we were trying to do for people actually did good for people.

Adam’s research has contributed to new standards designed to measure the effects of humanitarian work. The goal is to use…

numbers, quantifiable metrics to say, this is how we know we're making an impact, this is what we should be doing. And we continue to do that in a way in the field that shows our interventions are actually helpful and impactful.

Making sure humanitarian aid is effective is more important than ever. According to the UN, 360 million people around the world need humanitarian assistance. Violence in places like Ethiopia, Myanmar, and Armenia has caused over 100 million people to lose their homes. That’s the highest number of displaced people since World War Two.

Gaza is in the news today, but it probably won't be a year from now. Even though the fighting may not be done a year from now and even though the after effects of that fighting are going to continue for many, many years decades to rebuild and reconstruct. And so it's important, I think, for, you know, people who are listening to keep in mind that all the things that you see in the news about crises are just a tiny piece of the much broader ecosystem that's out there in terms of humanitarian need.

It’s easy to get overwhelmed by all of this suffering, and think of these conflicts as problems that happen somewhere else, but not here. Craig says that’s a mistake.

Having worked on a ship and pulled 1000s of people out of the water, and seen and heard the horrors that they had gone through. I was grateful every day that I had stability in my life. And I could not imagine for a minute what their journey must have been like. And I think back to all of the discussions that we're hearing either on the southern border today or over the past decade with the massive number of people who've been forcibly displaced. And I try to remind people that during World War Two Eastern Europeans, so Greeks, Yugoslavs, in a time of instability, many fled to refugee camps in the Middle East, including in Aleppo. And so it was not that long ago that our forebearers, our parents, our grandparents, were in a moment of instability. And it's not completely inconceivable that in our own lifetimes in the near future, we could be as well. So to have that lens of empathy, I think is remarkably important. We forget our past. But we may see it reemerge in our own future, and we need to think about how that would impact us.

I think that's a good note to end on. Adam, Craig, thank you so much for taking the time to talk about this today.

Thank you for having us.

Pleasure to be here.

Narration:

Dr. Craig Spencer is an emergency medicine physician and an Associate Professor of the Practice of Health Services, Policy and Practice at the Brown University School of Public Health.

Dr. Adam Levine is a Professor of Emergency Medicine, and Health Services, Policy and Practice at Brown University. He is also the Director of the Center for Human Rights and Humanitarian Studies at the Watson Institute for International Public Affairs as well as the Associate Dean for Global Health Equity in the Division of Biology and Medicine at Brown University.

Humans in Public Health is a monthly podcast brought to you by Brown University School of Public Health. This episode was produced by Nat Hardy and recorded at the podcast studio at CIC Providence.

I'm Megan Hall. Talk to you next month!