Rebuilding after catastrophe? A missed opportunity for health and social change

By Rosalind Steege

The recent Ebola death in Sierra Leone takes the official death toll from the epidemic up to 11,316, though this is likely an underestimation. The news comes just days after, on the 14th January 2016, the Ebola crisis in West Africa was declared to be over. Over the past 22 months Ebola has taken the lives of people from 6 countries; Liberia, Guinea, Sierra Leone, Nigeria, the US and Mali and following recent events, is still threatening the lives of those in Sierra Leone. Unfortunately, this news serves as a wake up call for those in the global community that had breathed a sigh of relief and demands reflection and lesson learning. Ebola is just one of the many crisis the world faced through 2015, which also saw the Nepal earthquakes, Yemen civil war, South Sudan conflict and the Syrian refugee crisis to name but a few. So, what have we learnt? What is the most effective way of rebuilding a country after catastrophe?

A seminar hosted by the Guardian’s Global Development Professionals Network on a cold January evening in London aimed to answer just that. The panel consisted of humanitarian disaster experts, including Lewis Sida, Humanitarian consultant; Ben Webster, Head of Emergencies at British Red Cross; Kate Muzwehi, Director of people and performance at Restless Development; David Alexander, Professor of risk and disaster reduction at UCL; and Jo Kemp, Practice lead for governance and state buildings at Crown Agents. The Guardian’s environmental editor, John Vidal, chaired the panel. I went along to understand not only how the humanitarian and development community copes with responding to these disasters, but how we can ‘build back better’.

The seminar opened with a powerful film covering the effects of the recent earthquakes in Nepal and an insight into how the community are not only coping with the aftermath, but rebuilding lives and livelihoods. The number of natural disasters has risen from a reported 70 in 1970 to a devastating 348 in 2005. This is in part due to changes in the way natural disasters are counted and increased media reporting. However, with climate change likely to increase the frequency of natural disasters, coupled with a growing population and a world that is becoming ever more connected, we must be prepared for not only an increase in frequency of humanitarian crises but increasing numbers of those affected.

The discussion, drawing on the huge wealth of experience present, both from panel members and the audience, unearthed four key takeaways when thinking about responding to crises: 1) Restoring livelihoods should be a priority. In the wake of a disaster (with the exemption of epidemics) once people are sheltered and have access to clean water, the next step, which could be easy to overlook, should be thinking about restoring livelihoods. Lessons can be learnt from Haiti, where food came flooding in after the earthquake suppressing farming costs and causing a secondary disaster, and from L’Aquila region in Italy (which experienced an earthquake in 2009) where roughly 16,000 jobs were lost as companies moved out and the economy ground to a halt. This is where the private sector really has a role to play in empowering communities by providing continuity of employment or microloans to help local famers or traders restore their operations following a disaster “…instead, of thinking about building houses we need to focus on employment” Professor David Alexander.

2) Engaging communities and working with them to understand local contexts is at the crux of sustainable development and never is this more apparent than in the wake of disasters that shake communities to the core and leave them weakened long after the world’s media have left. As Lewis Sida commented, “in these situations it is often the local community that helps first so you can’t ignore them – in fact the most effective responses plug in to these capacities”. This point was illustrated by Kate Muzwehi discussing importance of utilising young community workers during the Ebola outbreak to act as social mobilisers and ensure communities listened to messages around safe burials. Importantly, these members will remain in the community once aid agencies have withdrawn to continue this role, without even the need for a handover. Perhaps more notably, these community workers are also tasked with holding governments accountable to commitments made, such as health system strengthening. Experience from the COUNTDOWN programme, which is aimed at eliminating NTDs, identified that in Liberia, in the wake of the Ebola crisis, close to community providers (CTC) were critical in re-building the trust between the health system and communities that had broken down during the epidemic. Here we see CTCs as critical agents of social change.

3) Rethinking funding for disaster relief may help to alleviate some of the challenges cited by the panel. Ben Webster suggested a paradigm shift was needed to move away from project specific funding to a more holistic, long-term funding cycle and that we should be more accountable to the communities we are serving rather than the donors. For too long political decision-making has driven donor priorities as opposed to the key development priorities of the country. Other issues discussed were around allocation of funding; high profile disasters such as the 2004 Tsunami raised $4.5 billion by the UN, whereas at the same time the $30 million needed for the Darfur genocide could not be raised and these funds are non-transferrable. This also highlights the role of the media in donor decision-making and funding priorities and suggests stronger linkages need to be made between these sectors to ensure they work together effectively. Another side effect of unequal distribution of aid donations is, in those crises with large funding, there can be a rush to spend money to avoid questions being asked around slow disbursement of funds; following the Tsunami this lead to some fishermen in Sri-Lanka receiving several boats each in a desperate effort to restore livelihoods.

4) Greater co-ordination across the humanitarian sector is required to ensure that as the sector continues to expand, effort is not wasted co-ordinating staff and is instead concentrated to help those on the ground. Additionally, more could be done to ensure learning is being shared from past relief efforts and that when humanitarian crises are over, effective handovers are made to the development community. Despite large relief budgets Haiti is still developing 5 years after the earthquake, as one Port-au-Prince resident put it “Haiti is an outdoor museum of failed projects”, which begs the question why these mistakes keep being made? Ben Webster suggests a three-pronged approach is needed to avoid this: 1) continuity of professionals across projects 2) facilitating a culture of learning instead of blaming and 3) ensuring the systems and processes are in place to enable learning. I would also add to that a culture of reflexivity; we should look at the lesson learning in times of crisis that can lead to more effective systems as they are being re-built. For example, in a recent stakeholder workshop linked to the COUNTDOWN programme and funded through the health systems global thematic working group on fragile and conflict affected states, we saw that in Liberia, the supervision of general community health volunteers (gCHVs) during the Ebola outbreak was highly effective. Harnessing the mechanisms that facilitated regular and detailed supervision is critical so that it is not lost as gCHVs begin to resume activities not linked to the Ebola epidemic.

On reflection, these are four insightful and practical strategies for improving our reactions to crises however, this thinking seems to miss the unique window opportunity that comes in the wake of a disaster; the opportunity to ‘build back better’. Liverpool School of Tropical Medicine recently held a seminar on ‘Building Back Better: gender and post-conflict health systems’ focussing on just this opportunity, and in particular the opportunity for social reform in gender and health. Taking for example Ebola in Sierra Leone, where gender and social norms meant that women were disproportionately affected due to their caring roles, the humanitarian response failed to adequately integrate gender equality advocacy strategies in their response; this is a lost opportunity in ensuring a gender responsive plan that addresses the multiple ways in which Ebola affects and is shaped by gender roles within and beyond the health sector.

Lewis Sida touched on this concept of creating social reform when it was suggested to him in the wake of the 2004 Tsunami whilst working with fishermen that it was a prime moment to rethink the fishing practices. Mr. Sida confessed that this type thinking goes against what feels natural for humanitarian aid professionals who are focussed on rebuilding the destruction in front of them, but if we don’t take this approach and humanitarian aid doesn’t integrate social reform policies into their work we have missed an opportunity for change. This is the approach that will take us beyond disaster response to a proactive focus on risk management – building more responsive systems – building back better.