Evidence Aid: The humanitarian relief evidence problems and what

can be done? Oxford, Sept. 26, 2011

Hey CERN, 186,282 miles per second, it’s not just the law, it’s a good idea!

Outline

• World is changing

• We have a minority lens

• Politics not ideal

But we can make headway via:

Donors

Self and peer expectations

Pushing logical next steps like defining “proven”

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1960 2000

Global

Nigerian Civil War: Problem, who was malnourished?

http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science/journal/01406736

QUAC Stick Developed

•

doi:10.1016/S0140-6736(72)91323-2 | How to Cite or Link Using DOI Copyright © 1972 Published by Elsevier Science Ltd.

Permissions & Reprints

Volume 300, Issue 7769, 22 July 1972, Pages 143-146

PATTERN OF PROTEIN-CALORIE MALNUTRITION IN YOUNG

CHILDREN ATTENDING AN OUTPATIENT CLINIC IN

BAGHDAD

Adnan Shakirb, c, a, M. Demarchib, c, a and N. El-Millib, c, a a Department of Pædiatrics and Child Health, Baghdad

University Medical College;, United Kingdom b National Nutrition Institute,, Baghdad;, Iraq c and School Health Service,, Baghdad, Iraq

Available online 26 September 2003.

http://dx.doi.org/10.1016/S0140-6736(72)91323-2http://dx.doi.org/10.1016/S0140-6736(72)91323-2http://dx.doi.org/10.1016/S0140-6736(72)91323-2http://dx.doi.org/10.1016/S0140-6736(72)91323-2http://dx.doi.org/10.1016/S0140-6736(72)91323-2http://www.sciencedirect.com/science?_ob=HelpURL&_file=doi.htm&_acct=C000002018&_version=1&_urlVersion=0&_userid=18704&md5=6d9c02baeb49680a4c32f9e84708b47chttp://www.sciencedirect.com/science?_ob=HelpURL&_file=doi.htm&_acct=C000002018&_version=1&_urlVersion=0&_userid=18704&md5=6d9c02baeb49680a4c32f9e84708b47chttp://www.sciencedirect.com/science?_ob=RedirectURL&_method=outwardLink&_partnerName=936&_udi=B6T1B-49MF3KY-520&_pii=S0140673672913232&_origin=article&_zone=art_page&_targetURL=https://s100.copyright.com/AppDispatchServlet?publisherName=ELS&contentID=S0140673672913232&orderBeanReset=true&_acct=C000002018&_version=1&_userid=18704&md5=1bcb1f53310f45c1f5df1db13c8dc73fhttp://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science/journal/01406736http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=http://www.sciencedirect.com/science/journal/01406736

# wars by Type, 1946-2003. Source: R Garfield & GBD Initiative

Trends in Child Mortality Relative to MDG4

Sub-Saharan Africa

South Asia

Latin America

East Asia

Under-

Five

Mortality

Rate

244

188

171

62

206

129

92

42.6

122

54 31

17.8

123

58

36

19.1

1970 1990 2004 2015

} MDG4 Goals Source: The State of the World’s Children, 2006

Changing patterns of world's population exposed to conflict, on a conflict

intensity scale of 1-10 (1=lowest intensity, 10=highest intensity)

0

50000000

100000000

150000000

200000000

250000000

300000000

350000000

400000000

450000000

1951

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1969

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1975

1977

1979

1981

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1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

1 2 3 4 5 6 7Source: Richard Garfield

Baseline measured or comparison group available

Yes No

Impact cannot be shown

Level of project evaluation the same as or logical with the level of implementation

No

Yes

3 essential criteria of causation met, ideally with at least one other

No

Valid indicator used with valid data collection methodology

No

Impact = difference between baseline or comparison rate and measured rate

Place&time Task

Serbia 8/02-7/03 Improve nutritional quality, HH income

Serbia, Kosovo, 7/02-6/03 Help 10,000 IDP’s return, psycho-social, winterize

Macedonia 5/02-12/02 Provide health care to refugees & returnees

Balkans 6/02-6/03 Reduce dependence on aid of chronic EVI’s

Bosnia, Croatia 5/02-4/03 Induce stable incomes, independence for EVI’s

DRC 1/02-5/03 Primary Health Care (PHC) for 15,000 refugees

Tanzania 1/01-12/01 PHC for refugees

Kenya 1/02-12/02 PHC for refugees

Uganda 1/02-12/02 Achieve food self-sufficiency

Eritrea 9/01-9/02 “increase life-saving PHC activities”

Rwanda 7-9/02 Provide PHC, Water and San. to returnees

Sierra Leone 2/02-4/03 Provide medical care via at least 13 clinics

Guinea 1/02-12/02 Provide mental health services to refugees

Guinea 2002 Induce econ. self-sufficiency, reduce SGBV

Guinea 2002 Provide PHC to 60,000

Place&time

Serbia, Kosovo, 7/02-6/03

Macedonia 5/02-12/02

Balkans 6/02-6/03

Bosnia, Croatia 5/02-4/03

Guinea 2002

Serbia 8/02-7/03

Guinea 2002

Sierra Leone 2/02-4/03

Uganda 1/02-12/02

Eritrea 9/01-9/02

Kenya 1–12/02

Rwanda 7-9/02

Guinea 1/02-12/02

Tanzania 1/01-12/01

Serbia 8/02-7/03

Baseline N/A

No Baseline

Baseline measured

Place&time

Serbia, Kosovo, 7/02-6/03

Macedonia 5/02-12/02

Balkans 6/02-6/03

Bosnia, Croatia 5/02-4/03

Guinea 2002

Serbia 8/02-7/03

Guinea 2002

Uganda 1 – 12/02

Sierra Leone 2/02-4/03

Eritrea 9/01-9/02

Rwanda 7-9/02

Kenya 1-12/02

Guinea 1/02-12/02

Tanzania 1/01-12/01

Serbia 8/02-7/03

No Benefits Likely

Benefits document

Likely did good things,

not documented

Created 10X multiplier effect for psych-soc.

“Durable solutions” for EVI’s met with durable

Inputs such as school books, home repairs.

“Food self-sufficiency” & “Self-reliance”

Delivered 2885 MT of general rations.

Fig. 3: Incidence of Dysentery, Mtendeli Camp, Tanzania,

cases/1000/mo.

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J'9

8 F M A M J J A S O N D

J'9

9 F M A M J J A S O N D

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J'0

1 F M A M J J

Photo by Teun Voeten

Rape in San Francisco, 1970's

36.7

1.70.6

5

1.7

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Russell 1978 FBI SF FBI Nat. NCS SF NCS Nat.

Rate

per

1000 w

om

en

per

year

From D. Russell and R. Bolen.

Bolton Box

Good Bad

Expected Unexpected

Unique role of us to create robust metrics to go here

To look broadly and at long enough periods to really know what goes here

Bolton Box – Measles Vac.

Good Bad

Expected Unexpected

Less measles in those vaccinated

Child cries, very small # adverse reactions, not doing other things.

People gain trust in health system, staff morale goes up…

People prefer use of used syringes, staff will not do other things without extra pay…

Bolton Box – Micro Fin. for HIV+

Good Bad

Expected Unexpected

HIV+ moms have employment

With assets, women Become more Vulnerable to crime.

People gain self esteem, role model for their kids…

Women got HIV intentionally to get $200 loan.

Bolton Box

Good Bad

Expected Unexpected

Is it ethical to run a humanitarian program that cannot show a benefit?

Bolton Box

Good Bad

Expected Unexpected What goes here for

Democracy building child protection, child soldier reint. poverty reduction, rape counseling, community sens. safe spaces Surveys, research, teaching

From BBC, Oct 13, 2009. http://news.bbc.co.uk/2/hi/africa/8304721.stm

Summary

1. The “medical” & “cost effective “ model is not the majority view.

2. Political, rights-based, contextual issues stacked against evidence centered relief.

3. Financial accountability forces always on side of cost benefit / cost-effectiveness approach.

4. Ethics in the broadest sense require knowing what affects we produce.

Possible ways forward

1. Create donor incentives to learn & doc.

2. Establish consensus criteria on what it means to be “proven” and start getting donors to fund differently between types

3. Establish function audit mechanism among biggest donors.

4. Start developing a “professional ethos” like pilots and nurses.

Questions? Thank you!

“Count what is countable, Measure what is measurable. What is not measurable, make measurable.” Galileo From: Kaydos, 1998

Births 2500 grams, Mtendeli Camp, Tanzania

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J'98 M M

J S NJ'99 M M

J S NJ'00 M M

J S NJ'01 M M

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2500g

Inc. of Fever/Malaria, Mtendeli Camp Tanzania, cases/1000/mo.:

Source IRC

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J'98 M M

J S NJ'99 M M

J S NJ'00 M M

J S NJ'01 M M

J

Births 2500 grams, Mtendeli Camp, Tanzania

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200

250

300

J'98 M M

J S NJ'99 M M

J S NJ'00 M M

J S NJ'01 M M

J

2500g

Suppl. Feeding of

Pregn. Women.

3% delivering women syph.+