- Nassim Assefi
- Seattle, WA
- United States
doctor~novelist~creative curator~activist~thrillionaire, ZocDoc
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What's the most effective model of global health aid/development, given interventions can have complex, unpredictable and longterm impacts?
A debate is raging between those who believe humanitarian aid is corrupt, ineffective, and harmful (eg Dambisa Moyos of the world) and those who believe it is the moral imperative of wealthier nations to help the poor (Bill Gates, Nick Kristof, Paul Farmer, etc). As an idealistic young doctor with a privileged life and education, I wanted to give back to the world, starting some 20 years ago when I joined my first NGO. Since then, I've seen many different models of global health with variable effectiveness--Doctors Without Borders approach of relieving suffering but not building infrastructure, more standard NGOs that combine the two, large UN agencies (eg UNICEF, WHO, UNFPA, ICRC), medical diplomacy (free exportation of Cuban health workers), social entrepreneurship (eg Acumen Fund), missionaries, Gates Foundation/Global Fund/World Bank, international medical research posing as aid, etc. While objective successmetrics and monitoring and evaluation plans are now the standard part of most health interventions, what do we really know about the longterm, complex outcomes of our well-intentioned health interventions? Have we propped up an illegitimate government or strengthened a democratically-oriented one? Have we destroyed local economies or sustained them? Have we exacerbated brain drain or created jobs for internationals who want to return home? Weakened local infrastructure or strengthened it? Educated or misled? Oppressed the people we were supposed to help or empowered them? Please help me figure out the most effective way to use my medical and public health skills to improve health in a global context, and in doing so, help many others who are struggling with these issues. I would love to hear your experiences, perspectives, and ideas about how to do global health work right and how you might measure the complex, longterm impacts of what you propose. (Meanwhile, ironically, the US still lacks a decent, universal, and cost-effective health care system.)
Closing Statement from Nassim Assefi
This question continues to be an open and complex one. Philosophically, I tend to agree most with Vivienne and Samuel, but that still doesn't leave me with a concrete answer for how to spend my time and energy as a global health doctor who wants to have maximum impact or do most "good." Certainly, I believe in the long view, in the possibility of unintended negative or positive consequences of humanitarian action, in the importance of sustainability and environmental preservation, that we have to pay attention to local leadership and resources and avoid being humanitarian colonialists (and hypocrites who can't even pass a universal health care bill in our own country). Yes, we need solidarity, not just charity. We need trade and social entrepreneurship as well as aid. I believe health and health care are human rights, and perhaps having global health insurance for every citizen on earth is not a crazy ideal. One day, I hope to explore these ideas further in a narrative nonfiction book on the subject. In the meanwhile, you can follow me on Twitter to contiinue the conversation (@nassefi) or on my website once I update it (www.nassimassefi.com). Thanks to all who participated in this discussion. Thank you for caring and sharing.
Vivienne Eggers
I believe our sustainable vision should include an integration with systemic models from democratic nations. But I think sometimes we seek to over 'fix' a problem that doesn't need it, in third world. The major issue with aid we all know is that its administration may not always work out the way the family watching the telethon back home intended. Our aid models stem from ancient tithe systems that worked in local village community - one digs in pockets and puts them in the church plate or whatever. This continues - the local Aussie sausage sizzle to fund the volunteer fire brigade that will save the lives of many tree, man and creature. The local fundraiser supports society backbone and extends into the NGO model where professional marketers devise ways and means of extracting charity. But we are in a new phase - we are global society with global needs and global climate change and disasters. We have to become sustainable now in our governance.
I propose a PEACE model. I call it preservation of arts, culture and environment. We set up centres in regions where we can exchange international benefits with local values and knowledge. We run training programmes and support hospital and local health care. We exchange traditional knowledge and modern. We fund centres & acitivities from a profit making sustainable business. We let Indigenous people teach us values. We consolidate a local-intl exchange
Vivienne Eggers
If politicians or global governance allows DEMOCRATIC governed countries to be overruled by military threat or politicians in power (i.e. security council) then those countries must surely be breaching their own constitutional principles. One might argue - who wants a stuffy old justice body capable of overseeing governance? The answer is THE PEOPLE. The same people that vote in their country for a politician should have the right to petition the accountability of those that they give the responsibility to - afterall politicians are doing a job that we as people have paid them to do - that is look after our people and our country according to constitution. If they don't do it or if they behave badly - why should they get away with it? Because they have a big bomb? This is ridiculous childhood mentality! Mother Earth has the biggest bomb of all - as Japan will attest with nuclear melt down threat post earthquake.
This is not to attack democracy and the principles of our democratic founders. It just means we are really out of date for the way we live, think and breathe. Also with capitalism collapsing - do we really want to replace it with a communist model? Looking at Mao and the millions that died I think not.
Do we as human individuals want to keep giving our personal power away to people that don't know how to take responsibility? I demand a refund for poor customer service. Judges and the justice system has evolved long before and apart from the economic system. Common law enables a fairness through case precedent etc. And there is the right of appeal. In principle - no man or woman should be above the law under democratic law. So why are they?
Now that we have that sorted out - we can take economic and political factors out of aid and health care. Once we do that - we start to see a different community based model evolving. The system doesn't favour first world community either. Local disaster recovery is often charity
Vivienne Eggers
The bottom line is I feel, that helping others on the planet to survive is a 'good' thing however we choose to do it. It's good for us morally and it is good for us to survive as we now come to terms that we are so closely inter-related.
But strategically we have to act fast - and work toward sustainable survivorship and cultural resilience models. First world countries and former colonies had many generations to adjust through the capitalist model. It is unlikely to work for third world for any great duration. This is also because capitalism has already started to collapse in first world and is only being kept alive for the sake of a single global economy. The reason for the collapse is our society now realises that Earth is not such a great big waste bucket after all. We can't 'pooh' in other peoples back yards and leave our own clean forever. Sooner or later the stink catches up. This time has come.
We have much in blue print cultures that scientists are just learning - as man concurrently destroys he finds out what he is destroying and how valuable it is. Our education programmes and our strategies for aid and health care etc need to come from a proactive sustainable vision - and take the best of breed from private, NGO and governments around the world. Secondly we need to remove the systemic model developed - or better still we need to reform the United Nations so that it can reflect our current society - it is still based on the World War II security model. We are lucky to have it. But if we are going to live in a real democratic global society - then a glaring factor is that we have a war tribunal that rules over international law. This doesn't happen in a democratic country. In democracy People, citizens vote who represents them in administering government. If they act illegally or incorrectly - still accountable. At international level security council can veto law - even genocide. Politicians above the law.
Vivienne Eggers
The next step is to replace people for machines and this has happened in first world. This will be the progression in third world. All the communities that are rapidly developing and pushing up inflation internally so that the very poor can no longer survive - because their overall economy is 'booming' - will eventually also be replaced by technology. Jobs will go to machines and automation because the capitalist model is to make profit. It has to keep making profit margins through economic drivers.
This leaves the third world population sectors who are currently embracing capitalist wealth in a tenuous position. Can they handle development in the same way as the population sparse first world? Their societies and culture do not function in the same systemic socio cultural way. Instead capitalism may increase the wealth of few but leave a massive problem for the poor - as land is taken and agriculture that supplies the world food provisions becomes less. Land taken over for industrialization means less land for agriculture of food and medicines - natural ones. Industrialization increases pollution and strain of natural resources - forests, waterways and environ. I recently attended conference in India for legal and overall impact of accessibility of pharmaceuticals and medicines health care to the commons. Capitalist first world is rendering medicines unavailable as India and China are major producers. India must now comply with UN IP agreements. Patent issue.
Vivienne Eggers
Vivienne Eggers
Based my own personal findings in research and experiential application out in the great wide world- I believe the comments and your words reflect the continuing dilemma of global society and supporting those in need and disadvantaged, trying to maintain a democratic humanitarian ideal that some of us have been brought up to believe is our given right - others have earned the self respect through education and advantages given or supported - and some who out of sheer frustration at denial through resilience traits have sought to correct the imbalance that humans experience when they look outside their personal window of life.
The reality is that each of those statements or questions you ask is affirmative - i.e. 'we' have weakened local infrastructure and we have strengthened it. We have educated and we have misled. We have oppressed and we have empowered and emancipated. The reason is not purely because we live within the philosophical title of the 'Maya' or paradoxical life of opposites - although that is perhaps the crux of the issue. The experience of the dilemma of Peace and social injustice rectified through sustainable development comes back to two major issues.
The first is that we seek to 'help' others from 'intentions' and these intentions in systemic context are always shaped within the constructs and motives of the system. Who can fix a system from within the system? We must first step outside. For example - we may desire to develop infrastructure to help others in third world country. But the major driver or less public motive will be along the lines of economic unity and the capitalist 'democratic' model - what MNC or other transnational corporation needs to exploit the resources in the region
Laurens Rademakers 50+
Perhaps the answer will reveal itself if we rigorously apply Esther Duflo's empirical approach and really test models, before drawing conclusions. (But perhaps some ideologies have a problem with empiricism itself?)
One thing is certain, though: too many charity and aid initiatives are self-serving feel good projects the outcomes of which cannot be measured or tested.
Bill Harrison 10+
I think what we can do is give them tools to help themselves. We should, for example, ensure that every child on the planet has Internet access - the web truly is a form of freedom and power. I think we should also give every person the right to "vote" by which I mean, we should give them something on the order of 3 digitally created dollars per day just for being human, so they can legally allocate some social resources to where they think they should go. Demand-side economics, we could call it.
I think the bare minimum people need are 1.) Knowledge, connectedness, and the ability to collaborate that the Internet provides and 2.) A small, consistent "vote" on social resources, at least enough to keep their brains healthy. If millions of poor people had those two things, I think they would develop the ability to help themselves pretty quickly.
Tamar Hoffman
Samuel Ching
I believe that sustainable social enterprises are the way to go. Ashoka.org contains a treasure trove of information about how through innovation, people in developing nations are able to harness the power of market forces and create a better life for themselves and their community.
Samuel Ching
-Needs more political muscle. Currently, it is very much driven by NGOs (Partners in Health, Doctors without Borders etc.) and the various Foundations (Gates, Rockefeller etc.) Good governance is just as important as foreign aid contributions. Governments around the world must manage their resources carefully and establish clear and efficient channels through which proper healthcare can be delivered.
- Requires the fusion of both innovation (in terms of actual medical products and logistical innovation) and grassroots effort. Without either, reaching rural villages would be an immensely difficult task.
- Would be vastly improved with solidarity, amongst the various NGOs and between the NGOs and Governments. With combined resources, certainly much more can be done.
However, I believe that each country has its own unique set of circumstances and societal norms which demands its own healthcare model. No healthcare system around the world could be transplanted into another country wholesale. Although Singapore’s healthcare model has been lauded around the world, even Singaporean doctors acknowledge that such a model works due to the constant fine-tuning on the part of the government through feedback and that it is difficult to exactly replicate such a system elsewhere.
Nassim Assefi 200+
http://www.youtube.com/watch?v=Q0X2exKyC7k Dr. Stephen Bezruchka on the health of whole populations
http://www.youtube.com/watch?v=CvVydQqJfWo Dr. Wendy Johnson solidarity, not charity, a new paradigm for global health
Nassim Assefi 200+
Also just learned of a new "Critical Development Forum" at the University of Washington, run by students who are questioning aid approaches.
Based on this discussion, I received an email from a Singaporean high school student asking intelligent questions about the efficacy of aid.
Glad to know that others are discussing these issues!
Chris Ke-Sihai 200+
We had an interesting speaker a while ago who talked about technology that can change healthcare provision globally, without going into the economics/politics very much. (Her primary customers are NGO's.)
http://tedxmonga.com/en/videos-9-dec-2010/53-ting-shih-brings-telemedicine-to-the-world
Nassim Assefi 200+
Matteo Da Ros 10+
In my opinion imposing the help from the "developed nations" is partially wrong. Our life still is undeniably better but we cannot impose it as such. We should think historically how we get here: it was a slow process, it was done step by step. It means as a population we got use to it, the development of our life style was also followed at the same time by an awareness of it. We didn't have a model to aim to, we made our own model step by step, tuning it to the characteristics of our own culture. And now we are pressing the Third World to get to our standards skipping all the intermediate steps. This cannot work. Those people are losing their own culture trying to copy our one. Culturally, they should be able to develop their own culture independently.
What we can do is to educate them to do so. From the health care point of view we have to realize that the biggest improvements were not about the use of drugs, nowadays we don't leave better and longer because of them, but about a better culture: hygiene first of all, good diet, reduced heavy physical work thanks to technology. Prevention is the real deal, not drugs. From this point of view giving a basic knowledge about hygiene first and the basic use of modern drugs would be much more effective on the long term. Drugs are effective only if taken the right way, otherwise they make things worse: people in Africa are given drugs against tuberculosis for free, but they don't complete the treatment because there are not enough supply for everybody and those who gets the pills share them with their relatives; in this way nobody gets cured and p strains of pathogens develop that are resistant to the drugs. A school can be better than a sickbay.
Nassim Assefi 200+