Note: This essay was published in New Perspectives in Foreign Policy Vol 11, Summer 2016. A PDF copy can be downloaded here: https://www.csis.org/analysis/new-perspectives-foreign-policy-vol-11-summer-2016 

Introduction

June 13, 2015

Yesterday was our first full day in Delhi. We checked some sights and to-do’s off our list: exploring Humayun’s Tomb, wandering through the old bazaar into the Red Fort, getting barked off buy a dog in the Majnu ka Tilla Tibetan colony, smoking biris. It was hot, of course, and we returned as tired tourists.

Today we decided check out a different sector of this buzzing human hive. The Ghazipur landfill is one of Delhi’s three sites for waste collection, and we thought it would provide a thought-provoking contrast to the more manicured Hauz Khas area where we were staying. I had read a little about Delhi’s Himalayas, the truly looming environmental health crisis posed by unfettered dumping, and the rocky but hopeful road to sustainability. I don’t know if it was morbid curiosity, boredom with Lonely Planet’s suggestions, or some warped sense of obligation as a consumer of things “Made in India,” but I felt the need to see it for myself.

We took the yellow line north to Rajiv Chowk, transferred to the east-bound blue line and stood in the clean, delightfully air-conditioned subway car until we reached Anand Vitar-SBT. From there we asked an auto-rickshaw driver to take us to Ghazipur. We drew the outline of a big mountain in the air with our index-fingers. He took us to the mall. We asked people who responded in one-word English, then averaged the direction of hands waved, picked a direction and started walking.

The road was big and busy. We poked our way around cows, carts, people and puddles of what I choose to believe was just muddy water. Someone had said the landfill wasn’t far, but the horizon remained grey and unmountained as we walked. Then it darkened, the wind picked up and the dust pushed us to find cover in the shop of some mechanics, who smiled as we introduced ourselves in a foreigner’s language. The storm didn’t immediately subside, so we soon found ourselves pointing at things, saying their English descriptor and hyper-gesturing for them to tell us the Hindi translation. It started to rain.

We had learned the word for Sit from a young man we had met yesterday after he asked to take a selfie with him on his smartphone. We used it now – Berna? Yes yes, here, they motioned, bringing us under a real roof with a bench and a table. Now point, Cow. Hindi? Gai. Now point, Door. Hindi? Darbaza. Now point, T-Shirt. Hindi? Banyan. By the time we said goodbye, we could say Walk – Dotna. See – Degna. Big – Bari. Trash – Pindi. I may have written them down wrong, but we were just about fluent.

The rain didn’t stop, but lightened, and it was warm, so we didn’t mind walking. In the distance came a highway, and behind that, a gray plateau. The landfill was on the far side of the freeway, so we crossed and wandered down a dirt road and past a construction site. The inhabitants of the slum community at bottom of the bluff, who make their living sorting through the waste for recyclables, watched us as we shuffled up to the wall of carbon.

We didn’t climb it, or do much at all. We left shortly, feeling like we had wandered into someone else’s home and turned it into an expose.

And that is an accurate description of what I’m doing now. I don’t have much more to say about our field day, partially because I don’t know that much about Ghazipur’s past, present or future. I did read that the construction site we walked through is a future waste recycling plant. When operational, the plant will begin to turn Delhi’s waste into energy. While there is an obvious need to curb the urban refuse problem, the plant’s construction has generated controversy, as it will push Ghazipur’s human recyclers out of a job. Fortunately Delhi has some dedicated community organizers who are preparing the slum community for the transition to a more sustainable future by retraining residents for vocational and artisanal jobs.

There’s not really much culmination to this story. I fulfilled my odd fantasy to put Delhi’s urban development in some sort of perspective, and left confident that there’s a lot of trash out there. I’m sure other cities around the world are dealing with similar problems posed by population growth, rapid industrialization, mushrooming consumption of goods and related production of waste. As we rise to the challenge of treating the side-effects of our modern economy, may we be careful not to cut out those communities that have grown to rely on them.

It’s an important issue, so I’m going to write about it.

First some context. To say that Liberia’s gender equality movement has a long way to go is a profound understatement. Liberia is among the lowest countries on the United Nations’ Gender Inequality Index, competing with Afghanistan and the Democratic Republic of Congo (both considered active war zones) for who holds the largest gap between male and female opportunity.

Liberia has been free from civil war for little more than a decade. In any conflict, women’s bodies become part of the spoils, but Liberia’s violence displayed particularly gendered brutality. Reports of nauseating sexual assault – widespread gang rape, sons forced to rape their mothers at gunpoint, genital mutilation, etc – abound. The numbers are blurry, showing anywhere from 15-75% of Liberian women to be victims of war rape, but the conclusion is clear. Extreme violence against women was endemic.

Significant progress has been made since the end of the war. The election of Ellen Johnson Sirleaf (the first female President in the continent), the passage of new rape legislation, and the growth of community support networks are all testaments to a safer future for women in Liberia.

But the idea that women are mens’ property remains widespread and deeply rooted. Sande bush schools – secret, informal academies of housewiving that culminate in genital cutting rituals – continue to pull girls from primary and secondary school despite government efforts to shut them down. These “schools” indoctrinate girls as young as three years old on female subservience, and contribute to a pervasive culture of gender-based oppression. As one member of our psychosocial team explained, many women “don’t believe their husbands love them if they’re not being beaten.”

Unfortunately, cultural context means very little to an Ebola viron. For up to three months after an individual eliminates Ebola from the blood stream, discrete traces of live virus linger in the person’s breast milk or semen. So when we discharge survivors from the ETU, the psychosocial team gives them the talk. For females, no breast feeding. For males, abstinence or condom-covered sex.

(Note: while the Ebola virus has been cultured from the semen of survivors within that three month window, there is no reported case of contracting the disease from only sex. At least not yet. Previous outbreaks have been too small, with too few male survivors to find a case of survivor-to-partner transmission via semen. And this outbreak has so far been too big to trace exactly how a patient contracts the disease.)

Asking a survivor to help prevent Ebola’s spread by practicing safe sex may seem like a reasonable request, but the conversation is a melee of scientific evidence and cultural norms. Not all, but many men scoff at the idea of abstinence or using protection, especially if they’re married. If they don’t voice their opposition, their silence tells all.

“You could see his eyes glaze over,” said one psychosocial officer after an exit interview, “he was no longer listening.” The survivor left the ETU with a discharge kit carrying as many condoms as our stock allowed, but whether those rubbers were used, thrown or sold was ultimately up to him.

This reality has women in Liberia worried. They know they have little power over men in the home, and even less in the bedroom. If a woman’s husband survives Ebola, leaves the ETU, returns home and wants to engage in unprotected sex, there’s little she can do aside from pray. One national nurse is so concerned she has called for legislation to put male survivors into three months of forced isolation – Ebola prison. Once they’ve done their time, they can force their wives to have all the unprotected sex they want, at least they wont pass on the virus.

The science behind how this virus spreads bares a tough truth: if we are serious about ending Ebola, we must address gender inequality in the affected countries. That’s so much easier said than done, but it must be done, for it will decide whether Ebola stays an emergency or becomes endemic.

Until women in West Africa are safe from men, with each new male survivor, a new three-month countdown begins.

Sources

“A House with Two Rooms: Final Report of the Truth and Reconciliation Commission of Liberia Diaspora Project.” 2009. The Advocates for Human Rights.
http://www.theadvocatesforhumanrights.org/Final_Report.html

Azango, Mae. “The Costs for Girls: ‘Why I Welcome Leaders’ Decisions.'” Pulitzer Center on Crisis Reporting. 2012. http://pulitzercenter.org/reporting/liberia-sande-secret-society-government-shutdown-female-circumcision-mae-azango

“Human Development Report 2014 – Gender Inequality Index.” United Nations Development Programme. http://hdr.undp.org/en/content/table-4-gender-inequality-index

Lamere, Carolyn. “Domestic Violence in Post-Conflict Settings: Interventions, Shelters, and Policy Recommendations.” Woodrow Wilson International Center for Scholars. Event hosted July 24, 2012. http://www.wilsoncenter.org/event/domestic-violence-post-conflict-settings-interventions-shelters-and-policy-recommendations#field_files

“Liberia: No impunity for rape – A Crime against Humanity and a War Crime.” Amnesty International. 2004. http://www.amnesty.org/en/library/info/AFR34/017/2004

Rowe, Alexander et al. “Clinical, Virologic, and Immunologic Follow-Up of Convalescent Ebola Hemorrhagic Fever Patients and Their Household Contacts, Kikwit, Democratic Republic of the Congo.” Journal of Infectious Disease. 1999.

Scully, Pamela et al. “Conflict Profile – Liberia.” Women Under Siege. 2013.
http://www.womenundersiegeproject.org/conflicts/profile/liberia

“Percolating.” That’s the word I’ve heard people use to describe the current status of Ebola here in Liberia. That’s what Dr. Peter Piot meant when he said he expects the outbreak to last through the end of 2015. Containing Ebola has been hard; ending Ebola will be harder.

For responding clinicians, “percolating” means monotony broken up by moments of emergency. It means maintaining fully staffed ETUs across the region even if their beds are empty, because we’re not sure when and where Ebola will appear next. The contact tracers and community surveillance officers are working hard to track all the suspects, but when every person with fever, weakness, vomiting and diarrhea is a suspect, it becomes a monumental task. And if a hotspot arises in an area without the infrastructure to manage it, we risk letting all of Liberia slip back to what it was in August – dying of Ebola.

But it’s no longer August, and it seems we’re entering a new phase of this crisis, one marked by tentative recovery under the shadow of constant readiness. While certainly a cause for celebration, this phase carries it’s own challenges. As the country tries to balance crisis and recuperation, the relationship between national health system and the internationally-sponsored ETUs grows more complicated.

The local clinics and hospitals have begun to reopen, and they’re calling their staff back to work, staff who were hired by foreign NGOs to man ETUs when the response was scaling up. So while efforts to return to normalcy are a positive sign, the general shortage of healthcare workers means that for now, the national hospitals and the ETUs have to share.

Those health facilities that are accepting patients remain hindered by the constant threat of a new outbreak. Memories of fellow clinicians that fell to the virus are still so fresh. If someone arrives at a clinic exhibiting any Ebola symptoms, the clinic stops all operations and waits for an ambulance to remove the patient.

The vigilance required to prevent Ebola’s rebound slows a health system that, after being closed for months, is desperately trying to catch up. All those people that were sick before the Ebola crisis now need treatment more than ever. Meeting that demand without compromising safety is difficult, to say the least.

For the ETUs, different challenges exist. Every suspect requires proof of a negative Ebola blood test before a local clinic or hospital will treat them. Signed by a doctor, the certificates we give out act as a ticket to care. To receive one, your symptoms must have started 72 hours before your blood tests negative for Ebola (research suggests an Ebola-positive individual can test negative in the first three days because their viral load is so low). This means that Ebola-negative patients in acute distress have to wait for up to 72 hours before being transferred to a facility properly equipped to care for them. The delay is potentially life-threatening, but with Ebola still percolating in the region, there are few alternatives that keep the national health infrastructure safe.

As an anecdote, a week ago we picked a patient up from a local hospital for Ebola-like symptoms. The patient denied recent contact with a sick or dead person, but complained of new onset nausea/vomiting and the hospital reported a fever. She was also pregnant, early in her third trimester.

Once admitted to the “Suspected” ward of our ETU, we found her to be afebrile. The nurse on duty drew her blood, but since her symptoms had just started, she’d have to wait 72 hours for a second test to confirm she was Ebola-negative.

Overnight, the woman’s blood pressure spiked. When the next round of nurses donned PPE and entered the ward, they found her on the ground, confused and lethargic. The doctor on shift suspected the woman had suffered a seizure due to eclampsia or pre-eclampsia, a potential life-threatening complication of pregnancy.

Our treatment unit has none of the equipment to diagnose or treat this problem, nor should we. The growing network of ETUs across Liberia is not intended to replace the country’s normal health infrastructure. And building up our capacity to treat anything other than Ebola would only confuse a population that’s just beginning to understand and not fear the ETUs’ existence. “You have symptoms of Ebola? Go the the ETU, we don’t kill you, we’ll do our best to make you better. You have any other health problem? Go to your local hospital and stay away from the ETU, coming here is an unnecessary risk.” For very good reasons, we stick to treating Ebola and Ebola only.

While necessary, these protocols worked against our pregnant patient. By morning she had improved, but she still had 48 hours before we could retest and discharge her to the hospital for more definitive care. She made it, but not without placing significant stress on our clinicians, who could only watch, hope and wait.

As we enter the “percolation” stage of Ebola in Liberia, it’s important to remember that these are good problems, ones that stem from the flood of international support, the declining transmission rate and the slow reboot of the country’s health system. And for an Ebola outbreak of unprecedented scale, these problems will continue to evolve. The best we can do is our best, and attempt to solve them as they come.

I’m leaving today. I’m writing this because I know many Americans would prefer I don’t return. The concern is understandable.

“You could bring the virus back and put our community at risk of infection. The best way to mitigate this risk is to stop flights, close our borders, and physically seal our country off from the virus.”

I want to explain why this approach won’t work, and why the only way to keep us safe is to eliminate the Ebola virus at its source. It comes down to one truth– it is impossible to “close” our borders.

Borders have been porous since people started drawing them, and today is no exception. In July, commander of U.S. SOUTHCOM Gen. John Kelly explained that despite our well-funded efforts, anyone can travel into the U.S. “so long as they can pay the fare.” Kelly made it infallibly clear that it’s not because we don’t have smart enough drones or high enough walls. Our borders stay open because the people crossing are desperate enough to find a way through.

“But Ebola is in West Africa, so why worry about people crossing the border? If we stop flights from the infected region, our problem’s solved, right?”

Sadly, it’s not that simple. We could cancel all air travel between the U.S. and West Africa, but our government cannot force other countries (like Canada or Mexico) to do the same. If someone infected with the virus happens to find himself anywhere in North or South America and feels inspired to reach the U.S., there’s little our guns or walls could do to stop him.

I say this not to incite panic, but to illustrate a point. Whether we like it or not, our world is interconnected, and a person with Ebola anywhere puts people at risk everywhere. This virus will not simply disappear if we close our eyes and leave West Africans to “deal with their own problem.” Using our limited resources to prevent Ebola from “getting in” is futile, and only draws from our efforts to end the epidemic abroad.

Suspending flights makes it harder to control the spread of the virus in two ways. First, it makes it extremely difficult to get people and supplies into West Africa, where they’re desperately needed to prevent and treat Ebola. In fact, it was one of the reasons the epidemic got so bad – the world’s fear prevented responders from doing their jobs. Second, it’s much easier to track peoples’ movements across borders if they fly. As soon as they book a ticket, we know where they came from and where they’re going. By shutting down flights we force people to travel by car or boat, an epidemiologist’s nightmare.

“Ok then go, but don’t come back until you’ve been quarantined.”

Forcing anyone who’s been to West Africa into quarantine regardless of whether they show signs of infection strongly pushes people not to volunteer. Instead of supporting responders who join the effort, it criminalizes them.

When I agreed to respond to this epidemic, I decided to take a huge risk – with my job, with my school, with my life. If Minnesota had followed New Jersey and enacted a blanket policy of forced quarantine, I wouldn’t have been able to go. My school would have kicked me out and I could have lost my job.

Instead of panicking, Minnesota’s Department of Health has set up a plan for returning health workers that safeguards our communities but doesn’t force responders into quarantine unnecessarily. This plan is based on the most up-to-date information we have about the virus. You can check out their Ebola protocol at the MN DOH’s website, under “Active Traveler Monitoring.”

I am not the first Minnesotan to travel to West Africa to help contain this epidemic, nor will I be the last. The sooner we recognize that our health and safety is predicated upon the health and safety of the rest of the world, the sooner we’ll end Ebola.

Storytelling

An old and powerful story lies at the heart of our nation’s current border crisis. The story has a convenient protagonist – average, law-abiding US citizens such as you and me.

We were working hard to build our American dream, when suddenly a flood of foreigners snuck over our white picket fence. The migrants were dirty, dangerous and desperate to leech off our success.

In this story, America’s only mistake was creating something that our neighbors coveted.

Now all our hard work is under attack. We must choose between courageously defending our American way of life or watching the invaders erode all that makes our country great.

Many smart, well-intentioned citizens take this story as fact. They might have sat in PTA meetings at their children’s school as it dipped into the already tight budget to hire English as a Second Language (ESL) instructors. They might remember the family that used to run the local bakery, before the building was converted to a taqueria. They might know a friend’s teenager who was caught buying marijuana traced back to a Mexican drug cartel.

This narrative might feel real for them, but history proves it’s an anecdote. For the US as a whole, this story is a dangerous fiction, one that blurs our country’s role as the primary driver of our border emergency. We are not the victims of an immigration problem, but the creators of a refugee crisis. Here’s why.

Crash Course in Migration

First, let me define my terms. People move from one place to another for any number of reasons: economic opportunity, family unification, environmental shifts, conflict, divorce, adventure etc. Adding all these factors up for each migrant gives us a picture of whether they’re running towards or running from something.

The travelers that are running towards something are generally called immigrants. They choose to move in an effort to seek a better life for themselves and their children.

The travelers that are running from something are called refugees. Their move is less a choice and more a necessity for survival. They are fleeing war, natural disaster, persecution or unlivable poverty. They are not seeking a better life, they are seeking life period.

The forces that either draw people to a country or drive people out of one are called pull and push factors.

We as a nation like to believe that we only generate pull factors – high paying jobs, fantastic schools, top-of-the-line healthcare, Hollywood, etc. – but that’s less than half the story.

Pushing Latin America

Since the late 1800s, the people we’ve voted into power have directly intervened in almost every country south of our border. We’ve protected US interests with boots on the ground in Argentina, Cuba, Puerto Rico, Dominican Republic, Mexico, El Salvador, Bolivia, Venezuela and Columbia. We’ve orchestrated successful coup d’états in Nicaragua, Honduras, Guatemala, Chile, and Panama.

When I say “protected US interests,” I mean we’ve guaranteed US investments, undermined Communism and fought the drug trade. In 1954, the US Secretary of State John Foster Dulles (whose brother was then head of the CIA) directed the overthrow of Guatemala’s democratically elected government because it attempted to nationalize the holdings of United Fruit Company, an American corporation. As the Cold War intensified, US troops fought Communist-leaning guerillas in Chile, Guatemala, Nicaragua and Cuba. Through the School of the America’s, the US military trained regimes in Argentina, Uruguay and Paraguay (among others) to torture and “disappear” dissidents as a means of maintaining authoritarian control.

By the 1980s, direct foreign intervention began to fall out of favor with the US populace. Our government’s overt strategy of displacing legitimate governments with US-friendly puppets didn’t align with our image as a benevolent democracy.

To maintain our influence south of the border, we turned to economic coercion through international trade agreements. Financial advisors convinced leaders in Argentina, Bolivia, Chile, Costa Rica, El Salvador, Mexico and Nicaragua to take massive short-term loans from the International Monetary Fund and the World Bank (both largely controlled by the US) on the condition that they eliminate trade barriers and cut social-welfare spending. These loans, called Structural Adjustment Programs, destabilized their national currencies and threw their major job-producing industries into direct competition with the rest of the world.

For the first-world financial advisor, this meant progress through increased efficiency. But for the people living under structural adjustment, it meant they lost their jobs at the same time as food prices skyrocketed and their currency depreciated. In short, the standard of living plummeted to the point that many couldn’t afford to feed their families.

So if a US-backed coup-d’état wasn’t enough to force civilians to flee, add a Great Depression.

Now there are drugs. The ongoing War on Drugs began in the early 1970s, with a mission to cut off the supply side of the supply/demand drug economy. But with no strategy to stem America’s demand, our aggressive criminalization of marijuana, cocaine, opiates (heroine) and methamphetamines simply jacked up the sale price. Just Say No became Just Pay More.

In tragic irony, the War on Drugs has fueled the Latin American drug trade by creating a huge gap between the cost of production (in Columbia, Peru, Bolivia etc.) and the going street price in the US. In 2009, the head of the Sinaloa cartel in Mexico publicly thanked US lawmakers for keeping drugs illegal, saying “I owe my whole empire to you… The War on Drugs is the greatest thing that ever happened to me.”

Just as Prohibition bankrolled the rise of organized crime in the 1920s, the War on Drugs has created a warzone out of Central America. The scale and intensity of the drug violence has escalated to the point that General John Kelly, Commander of US SOUTHCOM, has declared it a dire threat to US national security. However, Kelly makes it very clear the threat is of our making:

“All this corruption and violence is directly or indirectly due to the insatiable U.S. demand for drugs… The malignant effects of immense drug trafficking through these nonconsumer nations [have accelerated] the breakdown in their national institutions of human rights, law enforcement, courts, and eventually their entire society as evidenced today by the flow of children north and out of the conflictive transit zone.”

To summarize, our history of military intervention, economic coercion, and illegal drug consumption has left many parts of Latin America a literal wasteland. While the elements that draw immigrants to the US are no doubt real, we’ve pushed Latin Americans out of their nations far more than we’ve pulled them into ours.

So What?

To Americans who say the children arriving at our border are “not my problem,” you may be right. You personally did not decide to overthrow Latin American democracies, or coerce their leaders to take loans their countries couldn’t pay back, or traffic drugs across their borders.

But for over a century, our lifestyle in the US has been predicated on the marginalization of an entire continent. You personally may not have made the choices that brought us to this current crisis, but you’ve probably benefited from them.

If you’ve ever eaten a Chiquita banana or bought imported avocados or tomatoes; if you’ve ever celebrated spring break in Cancun or Tijuana; if you’ve ever smoked marijuana or used elicit drugs… you’ve added your weight to America’s collective shove against our southern neighbors.

Our actions have created unlivable conditions in Latin America. Now mothers are paying strangers to escort their children hundreds of miles across dangerous terrain on the small hope that they can escape north.

History proves that the kids arriving at our doorstep did not come by choice. We pushed them.

Resources

Fischetti, Mark. “U.S. Demand for Fruits and Vegetables Drives Up Imports.” August 20, 2013. http://www.scientificamerican.com/article/us-demand-for-fruits-and-vegetables-drives-up-imports/

Kelly, John F. “SOUTHCOM chief: Central America drug war a dire threat to U.S. national security.“ July 8, 2014. http://www.armytimes.com/article/20140708/NEWS01/307080064/SOUTHCOM-chief-Central-America-drug-war-dire-threat-U-S-national-security

Kinzer, Stephen. Overthrow: America’s Century of Regime Change from Hawaii to Iraq. 2006. Times Books.

Nazario, Sonia. Enrique’s Journey: The Story of a Boy’s Dangerous Odyssey to Reunite with His Mother. 2006. Random House.

Rathbone, John Paul and Thomson, Adam. “Latin America: A toxic trade.” April 18, 2012. http://www.ft.com/intl/cms/s/0/fd055994-ca8f-11e0-94d0-00144feabdc0.html#axzz38sIp9YQl

Robbins, Ted. “Wave Of Illegal Immigrants Gains Speed After NAFTA.” December 26, 2013. http://www.npr.org/2013/12/26/257255787/wave-of-illegal-immigrants-gains-speed-after-nafta

Shah, Anup. “Structural Adjustment – A Major Cause of Poverty.” March 24, 2013. http://www.globalissues.org/article/3/structural-adjustment-a-major-cause-of-poverty

Theroux, Mary. “Voyage of the Damned War on Drugs.” July 24, 2014. http://www.huffingtonpost.com/mary-l-g-theroux/voyage-of-the-damned-war-_b_5621296.html

Weiner, Tim. Legacy of Ashes: The History of the CIA. 2007. Doubleday.

Wilson, Tamar Diana. “Economic and Social Impacts of Tourism in Mexico.” Latin American Perspectives. 2008.

The day before I left Leyte, I went for a run. My Ethiopian colleague joined me. We jogged down the side of the road for maybe a kilometer before turning onto the smaller, beaten dirt path that led down to the ocean.  People gawked and hooted as this odd pair passed them. I wondered what they thought – a lanky white guy and a shorter black man, obviously foreigners, loping through their recently devastated community. We passed the school, its roofs collapsed and courtyard sprinkled with debris. I asked my running mate if that school would be included in the WASH (water, sanitation and hygiene) rehabilitation project the International Medical Corps was starting. He doubted it, the school looked like it had sustained significant damage, and the proposal was for “quick fixes” only, schools that just need new faucets or a latrine to be declared ready for class to resume.

Quick fixes are common in any disaster-recovery portfolio, but in the Philippines, where the next storm season is only nine months out, it’s hard to hope for anything more. The international community loves the idea of “building back better,” but it’s much easier said than done. When a senior WASH program director and former civil engineer passed through our field site, I asked her if there was any trend towards connecting relief funding with improved resilience requirements. She didn’t try to hide how jaded she felt when she told me no, almost all grants for short-term reconstruction and recovery projects (lasting six months to a year) focus on returning communities to their baseline, pre-storm conditions. And by that time, we’d be right back in storm season, waiting for the next typhoon to restart the cycle.

We hit the beach and turned north, picking up the pace a little. The sun began to fall low on the horizon, and fishermen were dragging their boats up on the beach after a day at sea. They stopped to watch. Some nodded and smiled, but most looked tired. They had beached their vessels next to a ridge of sand dotted with palm wood crosses facing the ocean. As we approached, I worried if I was about to denigrate a burial site. Should I run on the inland side, or pass between the makeshift memorials and the ocean? Was I oblivious to a tradition and about to trample it? I didn’t know what to do, so I did what I’d seen locals do around churches and cemeteries. I bowed my head slightly, closed my eyes, and moved my hand from chin to chest, then from left shoulder to right, making the sign of the cross.

We passed other tributes to the typhoon on the beach – abandoned restaurants and hotels, sheet metal, lots of trash. We eventually stopped at a nice stretch of sand, took off our shoes and waded into the ocean. A group of Filipino boys came running up and watched us as we cooled off in the waves. Some looked skeptical – we had heard rumors of locals refusing to swim in the sea for fear of finding bodies in the surf.  The fear was understandable, but unfounded; it was six weeks since the typhoon, and the casualties had long washed up on shore or out to sea.

The boys laughed at us as we hopped back into our socks, trying to avoid filling them with sand after our dip. They chased us down the beach until they reached their cluster of shacks. We waved goodbye and continued jogging down the beach. As I turned away, I noticed a shoe partially buried in the sand. It was small enough to be one of the boys’. I couldn’t help thinking about its wearer. Was that kid alive, chasing foreigners with friends, or was the shoe just a tiny, tragic relic of an individual that became a statistic?

We eventually turned off the beach back onto the dirt road. Outside the school some teenagers were playing basketball, dodging the divots and shooting for nothing but net on a hoop with no net. They bounced the ball at me, yelling “dunk!” as I ran towards them. I went for it, and missed. I’m just glad I didn’t break their hoop.

There are definite examples of disaster creating the opportunity for profound development (Fan 2013). I hope Typhoon Haiyan proves to be one of those cases, and there are some pretty good reasons to be optimistic. Since 2010, federal legislation has pushed local governments to invest in disaster risk reduction, compelling them to set aside at least five percent of their budget for a Local Disaster Risk Reduction and Management Fund (LDRRMF). A more recent amendment authorized local governments to use up to seventy percent of the LDRRMF for pre-disaster preparedness; the other thirty percent is reserved for response (Preparedness issues in Philippines Typhoon Haiyan Recovery). Typhoon Haiyan also spurred the federal government to invest P500 million in the People’s Survival Fund, created in 2012 to help local governments become more resilient to climate change and climate-related disasters (Ranada 2013).

However, at the international level, a meaningful connection still needs to be made between short-term relief and long-term resilience. We can’t keep hopping from one disaster to the next, throwing money at them until basic needs are met, people stop looking desperate on tv, and the international community gets bored and moves on. If we do, I’ll be back in the Philippines again next year, or the year after, running on the beach, trying not to look for shoes.

Resources

Fan, Lilianne. “Disaster as opportunity? Building back better in Aceh, Myanmar and Haiti.” Humanitarian Policy Group. November 2013. http://www.odi.org.uk/sites/odi.org.uk/files/odi-assets/publications-opinion-files/8693.pdf

Ford, Peter. “Typhoon Haiyan: Can Philippines build back better?” The Christian Science Monitor. February 9, 2014. http://www.csmonitor.com/World/Asia-Pacific/2014/0209/Typhoon-Haiyan-Can-Philippines-build-back-better

Nguyen, Kim. “One hundred days since Typhoon Haiyan.” Aljazeera. February 18, 2014. http://www.aljazeera.com/indepth/features/2014/02/one-hundred-days-since-typhoon-haiyan-20142188436327673.html

“Preparedness issues in Philippines Typhoon Haiyan Recovery.” Global Disaster Preparedness Center. http://preparecenter.org/topics/preparedness-issues-philippines-typhoon-haiyan-recovery

Ranada, Pia. “P500M allotted for People’s Survival Fund, ecotowns.” Rappler. November 25, 2013. http://www.rappler.com/nation/44572-peoples-survival-fund-ecotowns-budget

My experience working as an Emergency Logistics Officer for the International Medical Corps in response to Typhoon Haiyan (Yolanda).

December 14, 2013

I’ve been in the Philippines for almost two weeks now, and I thought I’d write an update on my life here.

I landed in Cebu on Dec. 2, after a vortex of a plane trip that swallowed me up in Minneapolis and spit me out on the other side of the world.

The city of Cebu has become the hub for relief operations. It weathered the typhoon with minimal damage, it has a functional port and good market access, and it’s close to the affected area – 6 hours by ferry, 30 minutes by plane. Our Cebu-based logistics crew procures supplies based on requests from the people at the field sites. This means they either buy stuff in malls or markets, or order it from international suppliers, or request it from donors. Whatever the route, they do their best to support those working in the field by getting the things they need sent to them as soon as possible.

I spent the first few days of my contract there in Cebu, unjetlagging myself and getting a feel for my job. My second night in-country we headed down to the airport to unload a 747 full of 250 pallets of different aid items – food, tents, generators, medical supplies etc. Being on the tarmac to watch the process was a rush. In front of me towered the massive jet, and in the distance sat the C140s from the Royal Australian Air Force, preparing to fly goods and aid workers to Tacloban, Guiuan, and other severely affected areas.

Before our pallets could be dispatched to the field sites, they had to clear customs and be released from the shipping company’s warehouse, a whole process in itself. Luckily the Philippine government set up a “One-Stop-Shop” for processing relief supplies. Representatives from the Department of Social Welfare and Development (DSWD), the Department of Health, The Bureau of Food and Drugs, the Ministry of Finance (MoF), and the Department of Foreign Affairs (DFA) established a center where organizations (like us) awaiting big shipments of aid could come and get all the entrance/transportation papers stamped in one stop. It actually saved us a lot of time and energy. I think it’s a great example of how the Philippine government has paved the way for relief organizations to do their job, and it’s one of the reasons this response has been so efficient.

The next day we shuttled around a pair of German donors (who had funded the 747) so they could see where their donation was going and how it was getting there. That felt odd, that so soon after the disaster, we had to spend a day catering to foreign donors, a day that could have been spent procuring and dispatching relief supplies. But as my supervisor explained, without inspired donors, there’s not much we can offer the people in need.

I left for our operations base near Tacloban the night of Dec. 5, after a long day rushing around Cebu’s malls buying some key items for the field team: motorcycle helmets, rain coats, rubber boots, back packs, 3G wifi hotspots and of course, chocolate.

I arrived at the base early the next morning, after taking an overnight ferry from Cebu to Ormoc, then driving 3 hours across the island of Leyte. The ferry was packed with families returning to their homes, or what was left. One man told me they had to get back to plant the rice.

Our field office is located just south of Tacloban, in a town called Tanauan. I’m working with a team of about 20 people – 5 expat coordinators, and a crew of national doctors and nurses that came in from other areas of the Philippines to volunteer. After a disaster like this, IMC tries to move away from staffing their clinics with international medical volunteers as quickly as possible, and instead use local clinicians. The nationals are generally lower maintenance, harder working, and more attuned to the cultural nuances of healthcare in their country. They’re all really nice, and we all tend to get along, which is surprising considering we all share one bathroom.

We’re living in the top 2 floors of a family’s house. After the typhoon, many of the bigger houses still standing were rented out to relief orgs: the aid workers get a place to base their operations, the family gets an extra source of income to rebuild. The house we’re in is a 3 story cement building. The family who owns it runs a store out of the 1^st floor, and the father is the “Mayor.” His generator runs the street lights once the sun goes down, and in the aftermath of the storm, he’s put people to work rebuilding his warehouse.

There’s a lot to rebuild around here. Every village in the area is covered in broken sheet metal, trash and rubble from collapsed homes. The roads have been cleared, but they’re still lined with the makeshift tarp shelters of those displaced. Some have cardboard or plywood signs saying something like “HELP – NEED FOOD AND WATER.” There are also a lot of fires from people burning rubble as they clean up. Some nights it’s really smoky, and looking out from our balcony through the haze makes me feel like I’m in Apocalypse Now.

The days are long, but they go by fast. Up at 5:50, breakfast of eggs, rice, and some form of canned meat at 6:00, then check emails and start work. We recently got a shipment of reproductive health kits full of condoms, birth control, etc. that the clinicians are distributing, and so I restock them before the teams head out at 7.

Right now we have three teams, each composed of at least one doctor and some nurses. They go to three different villages a day, set up mobile medical units (MMUs) at the local health center, and treat patients till around 3pm.

Once they’re out the door, I update the excel sheets that track the use of medical supplies (gauze, tweezers etc) and pharmaceuticals. Then lunch: usually ramen and more rice, eggs and canned meat. Then I take supplies/medicines from our storage tent and stock them so the clinicians can replenish their kits when they return. I check that stuff out for them at around 5pm, then more excel before our team meeting at 7. Then dinner, misc work and emails, and if I’m lucky, a beer or two from the “bar” downstairs before bed at 11ish.

Based on what we’re hearing from the command team back in Cebu, we hope to wrap up the MMUs within the next week or so. The lines to the field clinics are growing thinner by the day and the pre-storm healthcare infrastructure is coming back online. There actually seems to be an overabundance of international medical missions providing direct patient care. We’ve heard reports of families going “doctor shopping” (showing up to multiple field clinics in the same day to get double the care and double the meds), and we’ve had problems getting the nurses, midwives and support staff who were working in these areas before the storm to show up and do their normal job. They (understandably) see the international medical missions working in their community as an excuse to ease off their duties, especially so close to the holidays (Christmas is HUGE in the Philippines).

The issue we’ve been trying to sort out now is how to dissolve our medical operations so we aren’t replacing their healthcare system and delaying the area’s recovery to baseline (pre-storm conditions), but how to do so in a way that doesn’t abandon anyone who needs us. It’s a tough line to walk, but we’re in the process of transitioning away from clinical care and towards programs focused on delivering nutrition and WASH (water, sanitation and hygiene) to the affected communities.  Although my job day-to-day is a lot of record keeping and I have little to say in terms of decision-making, it’s fascinating to watch our mission evolve right in front of me, and more than anything, it’s fun to be part of the team.

Love and hugs and happy holidays,

Will

My patient was an elderly man in his late seventies, let’s say seventy-eight. He only spoke Spanish, but I knew enough to get by, so I introduced myself and began asking my assessment questions. He was alert and oriented times one (A+Ox1): he knew his name, but nothing else about where/when/why he existed at the present moment.

But he knew he was in pain. A pressure ulcer on his left hip caused him to cry out with any movement. “Maria linda!… Dios por favor!” You didn’t need to know Spanish to understand.

I told him we were here to take him to his doctor’s appointment. The appointment was with a wound care specialist twenty or so minutes away. My partner got vitals while I grabbed his chart and tracked down his nurse for release signatures. As I walked down the hall, I looked at his list of medical diagnoses and confirmed my guess: late stage dementia.

When we lifted him over from his bed to the gurney, his pain got unavoidably worse. Every bump on the ride to the wound care clinic came with a sharp cry. I tried to make him as comfortable as possible, but nothing really helped. My patient’s problem was bigger than my powers; his ulcer likely came from weeks of lying in the same position in bed at a skilled nursing facility (SNF), cared for by overworked nurses aids who hadn’t the time or energy to turn him every two hours.

At the clinic, the doctor was backed up with patients, so we waited in the hallway for an hour, listening to our friend whimper on the gurney. When our turn finally came, we wheeled him next to the exam table and prepared to slide him over. Luckily, the doctor decided he could do his examination right on the gurney, so we helped him turn our patient on his side and hold him in position. As the doctor unwrapped the bandages, the smell of decay filled the room. The wound was deep, and the nurse cursed the patient’s caretakers as she wiped excrement out from inside it. Our patient’s whimpers rose to yelps.

The doctor measured the wounds size, took pictures, picked at some of the dead flesh, then re-bandaged it while muttering about the need to schedule surgery later next week. Another round of movement and pain for our patient. We got our paperwork in order, left the wound care clinic and returned him to his bed at the nursing facility without incident.

For many of us working in medical transport, this is a pretty common call: A+Ox1 patient needs wound care for a pressure ulcer. But for some reason this one in particular left an impression on me. Maybe it was the patient’s obvious pain, or the cracks in our health system that caused it, or the man’s lack of authority over how he’d spend his last months – at that stage of dementia, your life is no longer in your hands. Whatever it was, I left the call feeling like this wasn’t what I signed up for. When I decided to become an EMT, I did so because I wanted to tangibly help others. But with that patient, I felt like I was only contributing to and prolonging his pain. What was most frustrating was that every caregiver at every stage of the process, from SNF to transport to wound care specialist, was simply doing their job: fighting for life. But at least in this case, I wondered whether prolonging life was actually in my patient’s best interest.

It’s easy to use our job titles – EMT, nurse, doctor – as de facto proof that we’re “doing good.” But even if our intentions come from the right place, sometimes they don’t add up to an outcome that’s morally defensible. I still don’t know if for that patient on that day, I was an instrument of care or an instrument of torture.

As our aging population expands, it’s important to recognize how our healthcare system promotes or prevents death with dignity. When companies profit from every drug prescribed, every patient transported, every wound excavated, our good intentions can end up prolonging suffering instead of alleviating it.