Nassim Assefi

doctor~novelist~creative curator~activist~thrillionaire, ZocDoc

This conversation is closed.

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.

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    Mar 12 2011: I'm sorry Nassim - I want to add 'one more'. You request perspective on 'how to do global health work and that incorporates first and third world' which I think is important to note. Health care is a global issue not just a sustainable development or aid issue. I went into political discourse because the restrictions of our current governance impact our ability to deliver and administer adequate treatment regimes. Yet we have some very effective means of delivery in first and third world countries. Where it gets lost is through disadvantage - i.e. poverty.

    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
  • Feb 25 2011: I’m the Singaporean student that Nassim referred to below. I'm no expert on healthcare but I do have some view on the global state of healthcare. After the watching the various TED talks (by Dr Wendy Johnson, Ting Shih, Dr Ernest Madu etc.), reading up on healthcare literature (Mountains Beyond Mountains, Medical Geography) and web articles (www.nextbillion.net/blog/2011/02/22/integrated-healthcare-for-the-bop etc.), I’ve realised that improving the state of global health (in LDCs):

    -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.
  • Feb 15 2011: First of all I want to say that I am not a doctor and I have no direct experience of humanitarian help in developing countries. But I have watched several TED talks about this subject, reading newspapers and discussing with friends.
    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.
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      Feb 15 2011: Humanitarian colonialism is one of the subjects of my forthcoming novel, Say I Am You, so I couldn't agree with you more on your first point, Matteo. Education, especially of girls, is probably the most potent global health intervention we can do when you look at long-term outcomes. Yes, prevention is important. But there should be some equalizing of access to technology and pharmaceuticals. See my comment to Steve Garguilo's thread. Making antiretrovirals available to African AIDS patients is one such powerful example.
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    Mar 12 2011: Last one I promise.

    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
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    Mar 12 2011: Sorry there are so many posts.

    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.
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    Mar 12 2011: But the problem with this continued mode of approach is that Capitalism in its current format is a non sustainable model. The dragon eats its own tail - not joins it. As we have run out of the first world markets to exploit we have turned to third world for labor, materials and operations. This leads to the collapse of a SME small to medium enterprise sector in first world countries - and local consumerism must eventually decline. Why? because jobs decrease despite growing internal wealth.

    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.
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    Mar 12 2011: Under a capitalist driven development - it makes sense to relocate poor communities and give them housing health and other benefits to make way for economic mining or some other activity. Paved roads, electricity water etc. are all requirements for the exploiting capitalist - and what working conditions. Unfortunately this common practice of our current aid system DOES create animosity and resentment as those outside the developed zone still oppressed and suffering witness the wealth and natural resource exploitation of the visitors and the seeming buy out of the few that were assisted during the process. But bottom line - some good has come to some people who would not normally have received it. Hence the paradox.
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    Mar 12 2011: I'm impressed after reading your comment and those of the forum below in the level and approach that is currently being taken by students, advocates and those experienced in the filed - the weight is obviously tilted to those with humanitarian ideals.

    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
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    Mar 10 2011: .
    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.
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    Mar 10 2011: One of the horrible features of capitalism is that we can continue to sell our abilities and expertise to others so long as they do not acquire the abilities/tools/expertise to help themselves. To the extent that foreign aid keeps people dependent upon the wealthy, I think it is wrong.

    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.
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    Mar 1 2011: I am a strong believer that for development, both trade and aid are necessary. Aid following the traditional charity model is fairly accessible in developing nations as a rule. I feel that trade is now the key to development. Jacquline Novogratz makes a strong case for this through her Acumen Fund and promotion of patient capitalism, the "third way." I support her in this case. Melinda Gates also brings up a similar point when demonstrating how Coca Cola has used globalization and their power across many countries to encourage development. However, I still think that smaller businesses rather than large cooperations should lead the initiative to trade with the developing world. After all, large cooperations, while showing signs of aid through trade, have been charged with accusations of worker abuse and even abusing children in sweatshops. Small companies that can micromanage should lead the way in stopping such practices and forming true, global partnerships.
    • Mar 8 2011: I agree in principal with your proposition of trade and aid. However, its often said that the devil is in the details: ActionAid conducted a study and found that only 50% of the aid managed to be utilised as 'real aid'. We must be watchful of 'colonial humanitarianism' as Dr Wendy Johnson put it in her TedxRainier talk. Instead, we should learn to empower local communities.

      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.
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    Feb 21 2011: Two more useful resources on this subject, 10 minute talks from TEDxRainier:
    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
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    Feb 20 2011: I was very pleased to discover this webseries called "Beyond Good Intentions" by first time filmmaker and global aid worker, Tori Hogan: http://beyondgoodintentions.org/watchshare.php I've only watched the first episode but thought I'd share it here as it looks to be a good resource.

    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!
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    Feb 15 2011: I think as we in the developed world have, by and large, not figured out our own healthcare solutions yet, we're not really well-placed to be providing solutions to others.

    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
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      Feb 15 2011: Thanks, Chris. I agree that there's hypocrisy involved when we in the US don't even have our own health care system worked out and we're preaching to others about best practices. I watched the TEDxMonga talk. Telemedicine is an innovative tool that can help the situation a bit; it's actually most useful between auxiliary health care workers in the community or field and doctors in the cities (see the discussion started by Steve Garguilo).