Renewal Out of Ruin: Saving Lives and Building Capacity in Fragile and Failed States
Assistant Secretary, Bureau of Population, Refugees, and Migration
Before I begin my remarks, it is fitting that I note yesterday’s passing of Stephen J. Solarz, a true champion of human rights, democracy, and the interests of vulnerable people. As many of you know, Steve served in the House of Representatives for nine terms, beginning in 1974, and throughout those 18 years, was one of the most active members of the House Foreign Affairs Committee – ultimately chairing its Subcommittee on Asian and Pacific Affairs. Steve was a master at using all the instruments of Congressional power to promote positive change, and championed the rights of the most vulnerable – victims of conflict, abuse, and neglect, whether they were from Burma, Mozambique or Haiti. He defended refugees, and worked tirelessly to stem piracy in the Gulf of Thailand, rescue Vietnamese boat people, and safeguard the lives of displaced Africans, Central Americans, Poles and many others. His persistent advocacy for the dispossessed and disenfranchised will forever be a model for those seeking to make the world a better place.
And it is a model for us at the Bureau of Population, Refugees, and Migration, where protecting the most vulnerable must be at the core of our work. This is our mission – both due to the moral imperative of saving lives, and also because it enhances our ability to promote reconciliation, security, and well-being in circumstances where despair and misery not only threaten stability, but also the national security interests of the United States.
But how do we promote the interests and the well-being of the world’s dispossessed and disenfranchised when circumstances on the ground in so many places make access to populations of concern such a challenge?
Ideally, our international and nongovernmental partners should have full and easy access to conflict-affected populations. In some cases, international partners supplement or otherwise assist the work of national, provincial or local institutions. In Jordan and Syria, for example, Iraqi refugees receive benefits from the state, such as education, but the UN High Commissioner for Refugees (UNHCR) and others provide critical help as well. In Colombia, the government is the major provider of assistance to internally displaced populations, but the United States and others also assist. And even in cases where governments are without the capacity to meet the basic needs of the displaced within their borders, they are often prepared to permit access to international and nongovernmental organizations to provide protection and assistance – under terms and conditions that are acceptable and workable.
But what about those circumstances where governments demonstrate little inclination to meet the basic needs of the displaced, and do not even have processes of responsible management that would permit easy partnerships with international organizations that might wish to help?
Of course, this question is most compelling in the case of the internally displaced, to whom national governments have the greatest responsibility.
Writing off affected populations in these circumstances is not an attractive or acceptable option – or one that accords with international humanitarian principles. So, in such circumstances, what actions can concerned outsiders – donor governments, international organizations and other nongovernmental organizations – take to save and safeguard lives, and set the stage for sustainable development?
Just what lessons can we draw about effective response in such situations?
What better place to begin to look for lessons than the Bloomberg School of Public Health’s Mobile Obstetrics Medics project for Burma – an example of how innovative approaches can be applied to addressing humanitarian needs in even the most difficult of settings. Between 2005 and 2008 practitioners in this project documented a ten-fold increase in the proportion of women in their survey population who are attended at delivery by health workers who have been trained to provide emergency obstetric care. Over the same period, the unmet need for contraceptives decreased by 35% among the survey population, and there was a significant increase in the number of pregnant women who received post-natal visits, mosquito nets, and iron supplements to prevent anemia.
So how did the Mobile Obstetric Medics project obtain these results – and, again, what general lessons might we draw from this experience about providing assistance and promoting capacity in fragile and failed states?
Let me offer some observations drawn from review of the Mobile Obstetric Medics Project, as well as from my own experiences in related areas.
First, in environments involving fragile or failed states, we may be able to adjust our concept of presence without sacrificing an ongoing and even pervasive role. In the case of your project, access did not depend upon large and capital-intensive fixed facilities, or even smaller fixed sites whose establishment might have required complicated negotiations with national, provincial and local authorities – or security guarantees that would not have been attainable.
In such situations, a well-trained and dispersed network of providers who know the terrain and the communities can be a highly effective means of empowered health care delivery. In the Mobile Obstetric Medics program, community-based organizations were trained to provide maternal and reproductive health services in their communities in eastern Burma. This created a network of people with both the commitment and technical, linguistic, and inter-cultural skills to reach vulnerable and isolated populations with information and services. This corps of trained professionals works in mobile units, taking health care to isolated communities, rather than requiring individuals to come to a centrally located health center.
Second, a difficult operating environment should not prevent providers from adhering to best humanitarian and protection practices in the delivery of assistance. This can be critical if programs in uncertain environments are to be sustainable, build confidence among beneficiaries, and lay the groundwork for future broad-based development. In fact, a health delivery program is, by itself, evidence of this basic proposition – that vulnerable populations in fragile and failed states need much more than food and shelter to survive.
Third, while a community-based approach involving local providers can be of great benefit because it can firmly connect providers, over time, to the recipients of services, significant and long-lasting benefits will not emerge in the absence of dedicated training programs. As in the case of your project and its tiered approach involving three levels of health workers, training programs must be coupled with intelligent and effective processes for the delivery of services.
This leads me to a fourth point: that local capacity-building – as well as other developmental principles – should whenever possible be built into humanitarian assistance programs from the very outset of the response. This point was brought home to me most powerfully in Asia between 2005 and 2007, when I served as the UN Secretary General’s Deputy Special Envoy for Tsunami Recovery. A major goal of aid providers should be to put themselves out of a job, and with so much money and so many outside organizations flooding the region in the aftermath of the tsunami, that goal seemed attainable – and worth achieving.
Fifth, service providers operating in environments without public services and infrastructure must dedicate adequate data collection resources to avoid severe information deficits. As difficult as it is to obtain basic information in locations with limited infrastructure of all types, basic data collection is absolutely essential. The Mobile Obstetric Medics program’s network of providers has been trained to collect information on public health and related concerns, and this information – in Burma or in any place where the government does not generate reliable information – is critical for shaping programmatic interventions at the most local of levels and for informing possible support from the international community.
Sixth, when in doubt about the best programming options in difficult operating environments, you cannot go wrong by focusing on the well-being of women. Of course, we cannot minimize the possible complications of programming that might challenge existing structures of authority. But the benefits of smartly conceived programs for women can be overwhelming.
Ensuring the availability of reproductive health in diverse emergency settings is a critical aspect of providing for the overall health of populations around the world. There is a strong link between the reproductive health of a community, and that community’s ability to recover from crisis or calamity. Family planning and reproductive health care are indispensable to the health of women; the health of women is critical to the stability of families and communities; and women's health and participation in efforts to rebuild after a crisis are essential elements of achieving economic and social recovery, and development worldwide. Finally, experience has shown that the benefits that vulnerable women receive from aid, training and self-sufficiency programs are generally invested in their families and their communities.
Seventh, because unconventional humanitarian aid programs will in many cases operate across borders, an effective program of assistance should, if at all possible, be tailored to promote regional well-being and stability – or at least be developed with an appreciation of this issue.
Obviously, the benefits of a program in one country should not come at the expense of the people of another, and such negative effects also create opposition among governments in neighboring countries. In this respect, the Mobile Obstetric Medics project likely has significant benefits for the region – and for Thailand in particular. The availability of otherwise absent medical services within Burma has no doubt enabled many to avoid the need to travel to Thailand and to join that country’s population of undocumented Burmese. Moreover, the Government of Thailand has of late emphasized the importance of capacity building among Burmese, so this program seems quite consistent with their own stated policy objectives.
And I imagine that these particular benefits were very much in the mind of Dr. Cynthia Maung, the founder and director of the Mae Tao Clinic for displaced Burmese in Mae Sot, Thailand, when she came up with the original idea for this mobile project. During a June trip to the border, I had the honor of meeting with Dr. Cynthia, whose Clinic serves over 150,000 displaced Burmese in Thailand every year. The Clinic is now a lead local partner in the Mobile Obstetric Medics project, and continues to extend its reach for women in need.
And finally, in the absence of effective policing and law enforcement, aid providers need to consider promoting a range of options to safeguard security – and therefore ensure the humanitarian space necessary for effective assistance delivery.
In states that face ongoing challenges related to security and the rule of law, what should be the role of international or domestic security forces in ensuring humanitarian space and protection? To be sure, this question is not all that relevant to the current situation in Burma, but it is relevant elsewhere. For example, in the Democratic Republic of the Congo, how can we bolster the role of UN peacekeepers in providing protection? Moreover, how should the international community best promote security sector reform for Congolese forces, which may represent the best hope, over time, that internally displaced Congolese will enjoy more than a modicum of protection? And with the withdrawal from Chad of the UN peacekeeping missions, MINURCAT – the UN Mission in the Central African Republic and Chad – how can we best support the effort to build the capacity of a local, Chadian force that has affirmed its commitment to protecting Darfuri refugees?
Finally, how do we best ensure that security forces don't misuse or appropriate assistance for their own non-humanitarian purposes?
These are all important questions, which in fact highlight what may be the most critical point – and one, again, that seems particularly relevant to Burma: that in many circumstances, security forces will be unable or unwilling to promote effectively protect either humanitarian space or vulnerable populations. And when that is the case, concerned humanitarians must grapple with other strategies to ensure that people can be reached and assisted.
This is a complicated issue, but it seems to me that one essential requirement for creating a semblance of stability in an insecure environment is creating trust among the local population. And in this respect, the Mobile Obstetric Medics project may offer us very valuable lessons.
No two situations are exactly alike, but these and other factors may be of some use in informing efforts to provide assistance and protection to vulnerable populations in states that have very little indigenous capacity, very limited access or other obstacles to traditional means of providing aid.
In Somalia, for example, the strong presence of the militant group, al-Shabaab, has made it extremely difficult for international humanitarian organizations to access the south-central region and provide aid to vulnerable populations. As we think about future strategies to provide assistance, I believe we could benefit by some of the methods used by the Mobile Obstetric Medics project – and, in particular, your emphasis on extensive use of community-based organizations, and the avoidance of a specific presence in the area.
In Haiti, where our Bureau operates assistance programs near the border with the Dominican Republic, far from Port-au-Prince, some of your project’s lessons in training and use of local providers seem particularly appropriate – especially given the very limited capability of the central government and its limited connection to remote border areas.
In Chad, a difficult security environment in the eastern part of the country, which is now host to some 270,000 Darfuri refugees, is encouraging international nongovernmental organizations to limit their direct involvement in assistance activities – and instead to begin to rely more heavily on refugee camp committees. Here again, lessons from your experience in community development could lead to valuable insights.
And in Afghanistan, where the government has struggled with the effective reintegration of millions of returnees from Pakistan, regional stability should be – and is – a major factor in our programs of support for the return of Afghans from Pakistan.
In closing, I want to be sure that I haven’t overemphasized broader lessons at the expense of recognizing the signal accomplishment of your project: the effective provision of reproductive health services in an extraordinarily challenging environment. For this, we salute you and your important work.
There is an old proverb that states “When there is health, there is hope.” In one of the most difficult environments in the world, the Mobile Obstetric project shows us all that there is indeed hope for a better future. And for this, I express my appreciation to Johns Hopkins University and all the staff members of the MOM project.
Rest assured that the United States Government remains committed to promoting the reproductive health and human rights of displaced populations in Burma, and around the world.