sponsored links
TEDxBeaconStreet

Margaret Bourdeaux: Why civilians suffer more once a war is over

November 14, 2015

War doesn't just kill people; it destroys the institutions that keep society running, like utilities, banks and hospitals. Physician and global health policy analyst Margaret Bourdeaux proposes a bold approach to post-conflict recovery that focuses on building strong, resilient health systems that protect vulnerable populations.

Margaret Bourdeaux - Physician, global health policy analyst
Margaret Bourdeaux investigates the best ways to protect, recover and reconstruct health systems and institutions disrupted by war or disaster. Full bio

sponsored links
Double-click the English subtitles below to play the video.
So have you ever wondered
what it would be like
00:12
to live in a place with no rules?
00:15
That sounds pretty cool.
00:19
(Laughter)
00:20
You wake up one morning, however,
00:21
and you discover that the reason
there are no rules
00:23
is because there's no government,
and there are no laws.
00:26
In fact, all social institutions
have disappeared.
00:29
So there's no schools,
00:34
there's no hospitals,
00:36
there's no police,
00:37
there's no banks,
00:38
there's no athletic clubs,
00:39
there's no utilities.
00:42
Well, I know a little bit
about what this is like,
00:44
because when I was
a medical student in 1999,
00:47
I worked in a refugee camp
in the Balkans during the Kosovo War.
00:50
When the war was over,
00:56
I got permission -- unbelievably --
from my medical school
00:58
to take some time off
01:01
and follow some of the families
that I had befriended in the camp
01:02
back to their village in Kosovo,
01:06
and understand how they navigated
life in this postwar setting.
01:08
Postwar Kosovo
was a very interesting place
01:16
because NATO troops were there,
01:19
mostly to make sure
the war didn't break out again.
01:22
But other than that,
it was actually a lawless place,
01:26
and almost every social institution,
both public and private,
01:29
had been destroyed.
01:33
So I can tell you
01:35
that when you go into one
of these situations and settings,
01:39
it is absolutely thrilling ...
01:43
for about 30 minutes,
01:47
because that's about how long it takes
before you run into a situation
01:49
where you realize
how incredibly vulnerable you are.
01:53
For me, that moment came
when I had to cross the first checkpoint,
01:59
and I realized as I drove up
02:03
that I would be negotiating passage
through this checkpoint
02:05
with a heavily armed individual
02:09
who, if he decided to shoot me
right then and there,
02:11
actually wouldn't be doing
anything illegal.
02:14
But the sense of vulnerability that I had
was absolutely nothing
02:18
in comparison to the vulnerability
of the families that I got to know
02:23
over that year.
02:27
You see, life in a society
where there are no social institutions
02:29
is riddled with danger and uncertainty,
02:34
and simple questions like,
"What are we going to eat tonight?"
02:37
are very complicated to answer.
02:42
Questions about security,
when you don't have any security systems,
02:46
are terrifying.
02:50
Is that altercation I had
with the neighbor down the block
02:52
going to turn into a violent episode
that will end my life
02:55
or my family's life?
02:58
Health concerns
when there is no health system
02:59
are also terrifying.
03:02
I listened as many families
had to sort through questions like,
03:05
"My infant has a fever.
What am I going to do?"
03:08
"My sister, who is pregnant,
is bleeding. What should I do?
03:12
Who should I turn to?"
03:15
"Where are the doctors,
where are the nurses?
03:17
If I could find one, are they trustworthy?
03:19
How will I pay them?
In what currency will I pay them?"
03:22
"If I need medications,
where will I find them?
03:24
If I take those medications,
are they actually counterfeits?"
03:28
And on and on.
03:31
So for life in these settings,
03:34
the dominant theme,
the dominant feature of life,
03:37
is the incredible vulnerability
that people have to manage
03:41
day in and day out,
03:45
because of the lack of social systems.
03:47
And it actually turns out
03:50
that this feature of life
is incredibly difficult to explain
03:51
and be understood by people
who are living outside of it.
03:55
I discovered this when I left Kosovo.
03:59
I came back to Boston,
I became a physician,
04:03
I became a global public
health policy researcher.
04:06
I joined the Harvard Medical School
04:10
and Brigham and Women's Hospital
Division of Global Health.
04:12
And I, as a researcher,
04:15
really wanted to get started
on this problem right away.
04:16
I was like, "How do we reduce
the crushing vulnerability
04:19
of people living in these types
of fragile settings?
04:23
Is there any way
we can start to think about
04:26
how to protect and quickly recover
04:29
the institutions
that are critical to survival,
04:32
like the health system?"
04:35
And I have to say,
I had amazing colleagues.
04:36
But one interesting thing about it was,
04:40
this was sort of an unusual
question for them.
04:42
They were kind of like,
"Oh, if you work in war,
04:44
doesn't that mean
you work on refugee camps,
04:47
and you work on documenting
mass atrocities?" --
04:49
which is, by the way, very,
very, very important.
04:51
So it took me a while to explain
why I was so passionate about this issue,
04:55
until about six years ago.
05:00
That's when this landmark study
05:02
that looked at and described
the public health consequences of war
05:04
was published.
05:08
They came to an incredible,
provocative conclusion.
05:09
These researchers concluded
05:15
that the vast majority of death
and disability from war
05:18
happens after the cessation of conflict.
05:21
So the most dangerous time to be a person
living in a conflict-affected state
05:24
is after the cessation of hostilities;
05:29
it's after the peace deal has been signed.
05:31
It's when that political solution
has been achieved.
05:33
That seems so puzzling,
but of course it's not,
05:36
because war kills people
by robbing them of their clinics,
05:39
of their hospitals,
05:45
of their supply chains.
05:46
Their doctors are targeted, are killed;
they're on the run.
05:48
And more invisible
and yet more deadly is the destruction
05:52
of the health governance institutions
and their finances.
05:56
So this is really not
surprising at all to me.
06:00
But what is surprising
and somewhat dismaying,
06:05
is how little impact this insight has had,
06:08
in terms of how we think
about human suffering and war.
06:12
Let me give you a couple examples.
06:16
Last year, you may remember,
06:18
Ebola hit the West African
country of Liberia.
06:20
There was a lot of reporting
about this group, Doctors Without Borders,
06:25
sounding the alarm
and calling for aid and assistance.
06:29
But not a lot of that reporting
answered the question:
06:33
Why is Doctors Without Borders
even in Liberia?
06:37
Doctors Without Borders
is an amazing organization,
06:39
dedicated and designed to provide
emergency care in war zones.
06:42
Liberia's civil war had ended in 2003 --
06:47
that was 11 years
before Ebola even struck.
06:50
When Ebola struck Liberia,
06:54
there were less than 50 doctors
in the entire country
06:56
of 4.5 million people.
06:59
Doctors Without Borders is in Liberia
07:02
because Liberia still doesn't really have
a functioning health system,
07:04
11 years later.
07:08
When the earthquake hit Haiti in 2010,
07:09
the outpouring of international
aid was phenomenal.
07:13
But did you know that only
two percent of that funding
07:16
went to rebuild
Haitian public institutions,
07:20
including its health sector?
07:23
From that perspective,
07:25
Haitians continue to die
from the earthquake even today.
07:27
I recently met this gentleman.
07:31
This is Dr. Nezar Ismet.
07:33
He's the Minister of Health
in the northern autonomous region of Iraq,
07:35
in Kurdistan.
07:39
Here he is announcing
that in the last nine months,
07:41
his country, his region, has increased
from four million people
07:45
to five million people.
07:49
That's a 25 percent increase.
07:50
Thousands of these new arrivals
have experienced incredible trauma.
07:52
His doctors are working
16-hour days without pay.
07:56
His budget has not increased
by 25 percent;
08:02
it has decreased by 20 percent,
08:05
as funding has flowed to security concerns
and to short-term relief efforts.
08:08
When his health sector fails --
08:13
and if history is any guide, it will --
08:15
how do you think that's going to influence
08:17
the decision making
of the five million people in his region
08:19
as they think about
whether they should flee
08:22
that type of vulnerable living situation?
08:25
So as you can see,
this is a frustrating topic for me,
08:29
and I really try to understand:
08:32
Why the reluctance to protect and support
08:34
indigenous health systems
and security systems?
08:37
I usually tier two concerns,
two arguments.
08:41
The first concern is about corruption,
08:44
and the concern that people
in these settings are corrupt
08:46
and they are untrustworthy.
08:49
And I will admit that I have met
unsavory characters
08:52
working in health sectors
in these situations.
08:55
But I will tell you that the opposite
is absolutely true
08:57
in every case I have worked on,
09:01
from Afghanistan to Libya, to Kosovo,
to Haiti, to Liberia --
09:03
I have met inspiring people,
09:07
who, when the chips were down
for their country,
09:09
they risked everything
to save their health institutions.
09:11
The trick for the outsider
who wants to help
09:15
is identifying who those individuals are,
09:18
and building a pathway for them to lead.
09:21
That is exactly what happened
in Afghanistan.
09:23
One of the unsung and untold
success stories
09:27
of our nation-building effort
in Afghanistan
09:30
involved the World Bank in 2002
investing heavily
09:33
in identifying, training and promoting
Afghani health sector leaders.
09:37
These health sector leaders
have pulled off an incredible feat
09:43
in Afghanistan.
09:47
They have aggressively increased
access to health care
09:49
for the majority of the population.
09:53
They are rapidly improving
the health status
09:55
of the Afghan population,
09:57
which used to be the worst in the world.
09:58
In fact, the Afghan Ministry
of Health does things
10:01
that I wish we would do in America.
10:04
They use things like data to make policy.
10:06
It's incredible.
10:08
(Laughter)
10:09
The other concern I hear a lot about is:
10:12
"We just can't afford it,
we just don't have the money.
10:14
It's just unsustainable."
10:16
I would submit to you
that the current situation
10:19
and the current system we have
10:21
is the most expensive, inefficient system
we could possibly conceive of.
10:23
The current situation
is that when governments like the US --
10:27
or, let's say, the collection
of governments
10:31
that make up the European Commission --
10:33
every year, they spend 15 billion dollars
10:35
on just humanitarian and emergency
and disaster relief worldwide.
10:37
That's nothing about foreign aid,
that's just disaster relief.
10:41
Ninety-five percent of it
goes to international relief agencies,
10:45
that then have to import resources
into these areas,
10:50
and knit together some type
of temporary health system, let's say,
10:55
which they then dismantle and send away
when they run out of money.
10:59
So our job, it turns out, is very clear.
11:04
We, as the global health
community policy experts,
11:09
our first job is to become experts
in how to monitor
11:13
the strengths and vulnerabilities
of health systems
11:19
in threatened situations.
11:21
And that's when we see doctors fleeing,
11:24
when we see health resources drying up,
11:26
when we see institutions crumbling --
11:28
that's the emergency.
11:30
That's when we need to sound the alarm
and wave our arms.
11:32
OK?
11:35
Not now.
11:37
Everyone can see that's an emergency,
they don't need us to tell them that.
11:38
Number two:
11:42
places like where I work at Harvard
need to take their cue
11:44
from the World Bank experience
in Afghanistan,
11:48
and we need to -- and we will --
11:50
build robust platforms to support
health sector leaders like these.
11:52
These people risk their lives.
11:58
I think we can match their courage
with some support.
12:00
Number three:
12:04
we need to reach out
and make new partnerships.
12:05
At our global health center,
12:08
we have launched a new initiative
with NATO and other security policy makers
12:09
to explore with them what they can do
to protect health system institutions
12:13
during deployments.
12:19
We want them to see
12:21
that protecting health systems
and other critical social institutions
12:22
is an integral part of their mission.
12:27
It's not just about avoiding
collateral damage;
12:29
it's about winning the peace.
12:33
But the most important partner
we need to engage is you,
12:36
the American public,
and indeed, the world public.
12:40
Because unless you understand
the value of social institutions,
12:43
like health systems
in these fragile settings,
12:49
you won't support efforts to save them.
12:52
You won't click on that article
12:55
that talks about "Hey, all those
doctors are on the run in country X.
12:57
I wonder what that means.
13:02
I wonder what that means
13:05
for that health system's ability
to, let's say, detect influenza."
13:06
"Hmm, it's probably not good."
That's what I'd tell you.
13:11
Up on the screen,
13:15
I've put up my three favorite American
institution defenders and builders.
13:16
Over here is George C. Marshall,
13:23
he was the guy that proposed
the Marshall Plan
13:26
to save all of Europe's economic
institutions after World War II.
13:29
And this Eleanor Roosevelt.
13:34
Her work on human rights
really serves as the foundation
13:36
for all of our international
human rights organizations.
13:39
Then my big favorite is Ben Franklin,
13:43
who did many things
in terms of creating institutions,
13:45
but was the midwife of our constitution.
13:48
And I would say to you
13:52
that these are folks who, when our
country was threatened,
13:54
or our world was threatened,
13:57
they didn't retreat.
13:59
They didn't talk about building walls.
14:01
They talked about building institutions
to protect human security,
14:03
for their generation and also for ours.
14:09
And I think our generation
should do the same.
14:13
Thank you.
14:16
(Applause)
14:17
Translator:Leslie Gauthier
Reviewer:Camille Martínez

sponsored links

Margaret Bourdeaux - Physician, global health policy analyst
Margaret Bourdeaux investigates the best ways to protect, recover and reconstruct health systems and institutions disrupted by war or disaster.

Why you should listen

Margaret Ellis Bourdeaux, MD, MPH spearheads the Threatened Health Systems Project at Harvard Medical School -- an initiative that brings together public sector leaders, health care providers, academics, military strategists and private sector stakeholders to generate creative approaches to protecting valuable health system resources in countries affected by armed conflict and acute political crisis.

Bourdeaux's journey in global health began when she took a year of leave from Yale Medical School to work in refugee camps during the Kosovo War in 1999. She returned on her own after the war to trace families she had befriended in the camps and find out what had happened to them. Living in villages of Kosovo's countryside, she documented how these families struggled to care for their children, find health services and make a living in a society decimated by genocide and ethnic conflict. This experience impressed upon her the stark truth that war kills people by stripping them of their personal, community and national resources and institutions. Far more people died in Kosovo from the depleted health systems and institutions than from wounds sustained during the armed conflict.

Later experiences in Haiti, Afghanistan, Libya, Sierra Leon, Madagascar and Liberia revealed a similar pattern: armed conflict would decimate indigenous health institutions that never recovered, leaving people helpless when later crises -- earthquakes, epidemics, renewed conflict -- invariably struck. Strong, resilient health systems are the key to making war, disasters and epidemics less deadly.

After completing a joint residency in Internal Medicine and Pediatrics at the Harvard Combined Med/Peds Program, Bourdeaux was among the first graduates of Brigham and Women's Global Women's Health Fellowship. She has worked with the Office of the Secretary of Defense Policy to analyze the US Department of Defense’s global health projects and programs. She led a joint Harvard-NATO team of analysts to evaluate the impacts, challenges and opportunities international security forces have in protecting and rebuilding health systems in conflict affected states. She joined the faculty of the Division of Global Health Equity at Brigham and Women’s Hospital and Harvard Medical School in 2011.

This year she was awarded the prestigious Harvard Global Health Institute's Burke Fellowship in Global Health to investigate the responsiveness of foreign aid to health system distress and disruption. She is co-developing the first executive education course between Harvard Medical School and Harvard Kennedy School of Government for senior security policy makers on health system threat detection and response. In addition, she is launching Harvard Global Health Institute's first Summit on Threatened Health Systems in June 2017.

sponsored links

If you need translations, you can install "Google Translate" extension into your Chrome Browser.
Furthermore, you can change playback rate by installing "Video Speed Controller" extension.

Data provided by TED.

This website is owned and operated by Tokyo English Network.
The developer's blog is here.