Seeing the aftermath of typhoon Haiyan in the Philippines - heartbreaking images of people without any help or hope, and Anderson Cooper again bewildered on television by a government's lack of effective response - brings back memories of pretty much every single disaster in the last decade. The phrase "swift and coordinated response" has almost become a cruel joke because there is never the semblance of such from major actors during times of turmoil.

How many more disasters is it going to take for us to get our act together?

On first glance, it seems that the sheer scale of such events makes it impossible to plan. Lately though we have had plenty of opportunity for practice in the coordination of mass efforts to address tragedy (natural, and human-made). The 2004 Indian Ocean Tsunami reportedly killed 230 000 people, 2005 Hurricane Katrina was all the more tragic because it was marked by a pathetic response from the US Government, the 2010 Haitian earthquake left an innumerable number dead (estimates 30 000-250 000 dead) and the effects three years later are still widespread with homelessness, cholera and food insecurity. The terrifying list goes on and on with cyclones in Burma, tsunamis in Japan, floods in Pakistan - it seems there are no places that have been spared their share of suffering.

In all of these scenarios, hundreds of well meaning foreign "aid groups," organizations and agencies poured onto the scene, doing their best to alleviate suffering. I have no doubt that they helped in each and every case. But could they have done better? Can we do more when another inevitably tragedy strikes? The problem is that rarely do any of these groups talk to each other. Worse than this, they rarely share resources or expertise- essentially someone is reinventing the wheel each time. Furthermore, the public from whom they seek donations doesn't have a clear idea of who exactly does what (and I suspect neither do the groups themselves). Our news stations and social media channels boom with requests for donations, but it is a struggle to discern what Save The Children, World Vision and UNICEF do differently, and why they can't work together under one umbrella rather than competing for donations in times of crisis. Clearly competition in moments of turmoil is not best for the people suffering on the ground.

Ordinary people around the world have been incredibly generous during difficulties in foreign lands. Perhaps because the reality is finally sinking in that we as residents of this planet are all interconnected and a similar fate could befall any of us at any moment. President Obama outlined exactly what the U.S. Government is going to provide in addition to a disaster response team; "$20 million in immediate humanitarian assistance to benefit typhoon-affected populations, including the provision of emergency shelter, food assistance, relief commodities, and water, sanitation, and hygiene support" (via http://www.whitehouse.gov/typhoon). Interestingly the White house page also mentions another page where citizens can contribute donations http://www.interaction.org/ which claims to be "a united voice for global change" with 180 like-minded organizations. One doesn’t need to look very far down the "our members" page to realize that few of them have experience in disaster situations nor qualified personnel to be of any use working in the Philippines at this crucial point. The situation is akin to having an Ophthalmologist on hand when you have a shattered pelvis, all the impressive advanced-training in the world cannot make up for lack of experience in a relevant field. If groups are going to proudly display badges of “numbers helped” and “blankets handed out” then they also need to critically evaluate how many people they are failing due to lack of coordination with other groups.

There needs to be a chain of command, not a free for all by any and all organizations. The noble work of non-government actors certainly has a place - but it should be under the supervision of one coordinating party. When the government itself is incapable of taking the lead due to destruction in infrastructure or death of members, shouldn't the U.N. take charge? Isn't that one of the purposes for which it was created? If not, and I am sadly misinformed (or if UN staff are too busy holding meetings), then we need to create an organization with this one explicit mission - a FEMA v2.0 for world disasters (clearly not the FEMA during Katrina). If nothing changes, we will continue to witness the collective suffering of victims.

Varun Verma

 "Injustice anywhere is a threat to justice everywhere." Martin Luther King, Jr.  

This post is a question, an invitation and a challenge. How can we bring technologies we take for granted back home to those in the developing world? Many before me have spoken with outrage about the reality of two worlds; one of
abundance, and the other where people live like they have in centuries past. The situation is more complicated since even poor people may have some technologies like cellphones now, but vital lifesaving technologies remain nowhere in sight.  Some may argue that we still haven't solved the dilemma of how to provide basic care on a global scale, but I believe that the two don't need to be sequential. In actuality there are many scenarios in medicine where having a technology available is in fact necessary for the basic management of disease. We are doing our patients a disservice when they die from lack of access to a ventilator the same way as when they die from lack of access to an antibiotic. 

If one  looks back even a decade, there are health care delivery interventions present today in resource poor settings that seemed like a fairytale. Large scale organizations like The Global Fund to Fight AIDS, Tuberculosis and Malaria did
not even exist prior to 2002 and now reportedly it helps save 100, 000 lives every month. More recently there has been a movement to tackle non-communicable diseases (diabetes, heart disease, stroke, emphysema, cancer, and and mental
illness amongst others) since data reveals that they are the leading cause of death globally and 80% of deaths are in the world’s poorest countries (probably not all that surprising considering the unhealthy diet, exposures to toxins, hardships and lack of access to care that poverty brings with it). The field has done such a good job of building momentum for change. Why stop now?

Ensuring quality care in resource limited settings should be a given, but we need to do more than secure the supply of diagnostics and medications.  We need to move onto a second stage of global health work – advocating for the scale up of vital technologies. As a physician who practices both in one of the most advanced teaching hospitals in the world, and someone who works in rural Haiti – I am witness to striking disparities on a daily basis in what is available to help patients.  Undoubtedly every provider working in the field has similar stories, but two patient encounters while in Haiti have served as reminders to me that patients still die “stupid deaths” every day (to borrow a phrase from my Haitian colleagues). To be clear, this is in spite of the amazing work that has been done in other areas like vaccinations, providing anti-retrovirals to treat HIV, and community health worker programs.

During my first week here, a young woman came in to the internal medicine ward appearing rather well but with a complaint of shortness of breath. She had normal vital signs, appeared in no distress and had a normal physical exam. After some discussion with my colleagues, we ordered diagnostic tests including a chest x-ray and decided to observe her. Less than 48 hours later she was struggling to breath, and her mental status was compromised (and the chest x-ray was still not done). She required supplemental oxygen – which we provided from a tank. This worked at first until she decompensated further and what she truly needed was to be intubated and on a ventilator to buy us time to figure out what was wrong with her, and then to treat it. She ended up dying that night because of course we had no means to intubate her. Incidentally, there were a stack of two ventilators lying idly in the corner that I learned had been donated during the time of the 2010 earthquake. I was sad and incredibly angry to see the demise of a young woman who would have almost certainly seen the inside of an ICU in any well-resourced hospital. My colleague pointed out that there was no reliable electricity supply to plug the ventilator into, no steady delivery of oxygen (we had run out of tanks twice that week) and no respiratory therapists to ensure that things could run 24/7 as our patient would have required.

My second account is about a woman who presented with renal failure – struggling to breath, puffy, and with laboratory tests so elevated that my colleagues and I wondered how she was still alive. There is no hemodialysis available here. The patient and her husband shrugged when we conveyed how sick she truly was. She actually somehow did ok, and thankfully made it out of the hospital after we treated her with the medications we had available (not a substitute for dialysis). Perhaps unsurprisingly she returned a month later; sweating profusely and out of breath, carried in the arms of her husband – and this time both were panicked. My colleague turned to me as we examined her and asked if I heard what the patient said repeatedly while she desperately clung to our arms –“she told me she is going to die.”  The patient's sister stood beside her bed, hugging her around her waist, and giving her sips of water intermittently. We did our best to minimize her suffering by administering a benzodiazepine (anxiety medication) to calm her breathing and make her comfortable. She died less than 24 hours later.   Had dialysis been available I have no doubt the woman would not have died any time soon. This is the harsh reality of being a patient in a setting where otherwise abundant technologies are non-existent.

I do realize how costly technological interventions like ventilators and dialysis are, but cost is entirely an artificial creation (the health care debates raging in the US highlight this). Healthcare providers need involvement from other disciplines to
help us work on solutions like how to secure the electricity supply, and what to do when machines break. The real challenge lies in convincing change-makers that technologies we take for granted back home need to be mobilized quickly in places like Haiti, and not-necessarily waiting until we have perfected delivery of “basic” healthcare – because that may never happen. In addition to trumpeting our successes in the field of global health, we also need to bear witness to the horrific situations patients repeatedly face due to inadequate technologies, and advocate for change. The fact that we are at an unprecedented time in human history cannot be understated. We have the knowledge, wealth, and ability to eliminate health disparities. What we need is the consensus that all people deserve the benefits of modern technology, and the will to mobilize.

Varun Verma

One of the aspects of global health work that inspires me is the potential to make tremendous impact in health care outcomes in places where human beings are constantly endangered. A few exemplary organizations have perfected strategies to partner with local forces and apply evidence based medicine to create sustainable change in the face of unimaginably scarce resources. Despite success stories however- there is an army of not-so-useful actors that abound, who despite “doing” something (often involving social media frenzies, fund raising and conferences filled with backslapping self-congratulation), ultimately have no lasting impact due to uncoordinated and isolated efforts. Working as a medical doctor in Haiti over the past three years- I have come to witness some other disconcerting occurrences in the course of my global health activities.

Anyone who has worked on the ground in a resource poor setting quickly realizes that bad things happen (even in noble quests), and yet accounts of failure may fall on deaf ears of colleagues and supervisors alike because they're viewed as unsavory. Unlike prevailing academic medical tradition where morbidity and mortality conference plays an important role in education, and more importantly in preventing future adverse events – I have found that few feedback loops exist for healthcare providers working in resource poor settings. Oft cited reasons include cultural inappropriateness of such exercises as well as the 'politics' involved. Yet, by avoiding all discussion of what went wrong we are vastly underestimating the professionalism of our local colleagues, and are also magnificently failing our patients.

The vital need for honest self-policing and assessment aside, it has also become apparent that writing originating from some corners has become one sided and essentially propaganda of their own self importance. Clearly if the entire field of global health was so successful, we would not still be battling plagues long after effective cures were discovered. Much like negative clinical trials in the medical literature, I've found that most accounts of how consistently we fail our patients will not be published unless there is an accompanying silver lining or morale boosting lesson. Undoubtedly this stems from a fear that donors will be repelled by anything short of an inspirational seven minute speech accompanied by a neat slide-show. Since we are in the practice of medicine and not in the field of marketing, in addition to trumpeting our successes we also have a duty to report the horrific scenarios our patients repeatedly face due to inadequate diagnostics, supplies, and staff – and to push for change.

As if this neglect wasn't bad enough, it seems that more and more global health and development conferences these days seem to revolve around underlining hyped-up successes (often by professional circuit speakers), rather than the forging of real alliances between the different actors to enact change. True cooperation between those involved in health care delivery in resource limited settings may ultimately reduce waste, prevent duplication of efforts, and increase activity in areas of neglect. Instead, many of us seem to be constantly reinventing the wheel. Cooperation needs to be grounded on the level of local governments, people and organizations based in the places we serve, rather than trying to circumvent them – as 100 years from now when outside interests may have shifted the locals will remain.

Perhaps the reason there is a fundamental absence of cooperation is that increasingly organizations are fueled by greed (whether NGOs, foundations, universities or social entrepreneurs). Rather than profit, they compete for influence; desiring their brand stamped over people, product and infrastructure. Sometimes this is even at the cost of inferior care – so long as another organization is not “in charge.” Haiti is the perfect example of a situation where despite a relatively small population (10 million) and billions of dollars being poured in since the 2010 earthquake (through a disproportionately large number of organizations), we see few improvements in health or socio-economic indicators. Organizations here do simply do not talk to each other. They exist in their own putrid bubbles, often a stone's throw away from similar (if not identical) organizations. They do not share resources, they don't discuss strategy or goals, they just do. What they precisely do is often unclear– especially to the government / ministry of health – who are held prisoner to extremely limited resources and thus unable to enact meaningful health policy independently.

Despite my cynicism, laudable work is being done by a small number. Some groups exclusively employ Haitians to positions of leadership so that they may shape their country's future and are not dependent on the interest of outsiders. Other organizations have expanded their focus from purely medical delivery to fighting for adequate food, water, sanitation and housing – desperately trying to convince others (of the seemingly not-so-obvious reality) that all are interrelated. A select few refuse to accept the dogma that high quality care cannot be afforded to those most endangered in low resource settings and have taken arduous steps to ensure state-of-the-art facilities and training of local providers to match. For those working in Haiti for the long haul it seems a constant struggle to maintain funding streams to ensure that vital life sustaining work can continue once the reporters and cameras have departed. As I continue medical work in Haiti, my sincere hope is to see more honesty and cooperation between all organizations here – the present isolated path followed by some is not only unsustainable but also a disservice to our patients.

Varun Verma