Fixing what goes wrong after everything goes wrong
As the truck carrying Tom Kirsch crossed the Dominican Republic’s border into Haiti, the nation’s telltale signs of poverty—the primitive shacks, bare brown earth—came into view. There was no evidence of further catastrophe, of things that are even worse than the usual, grim day-to-day reality. That would change a few hours later when he wheeled into downtown Port-au-Prince, the Haitian capital. Two weeks earlier, on January 12, 2010, an earthquake had shaken the capital to its core, killing 237,000 people and leaving more than half of the city’s 2.5 million people homeless.
“The closer you got to downtown the more you saw people sleeping in any open space, including highway medians,” says Kirsch, MD, MPH ’87, an associate professor of International Health at the Bloomberg School and of Emergency Medicine at the Johns Hopkins School of Medicine. He serves both schools as an expert in disaster response. “Downtown itself was just horrible,” he recalls. Buildings were leveled. Streets were blocked by rubble, further hampering any relief efforts. The human toll was much worse, with harrowing examples of tragedy around each corner. An entire school of nursing students immersed in an exam—save one—was killed by the quake, which struck seven minutes before test time was up.
Even two weeks after the quake, one in three injured or ill Haitians had not been treated. “We’re talking about terrible bone breaks and deeply infected wounds,” Kirsch says. People needed water. Food riots had erupted when some earthquake victims thought aid wasn’t being distributed equitably enough.
“When a disaster happens, there’s a lot of attention paid. But after the news trucks leave, people are often left homeless and jobless for years. People forget that.” —Tom Kirsch
In the past year, Kirsch has traveled three times to Haiti, the poorest nation in the Western Hemisphere, not just to deliver emergency medical care but to ask questions about how the world and the Haitian leadership, also decimated by the quake, had responded to the crisis. Had there been enough concern about finding housing for people? How was aid being distributed? Why was health care being delivered so slowly? What were the nonprofit relief groups that regularly swarm to disaster sites doing right in Haiti? Where were they coming up short?
As co-director of the Center for Refugee and Disaster Response, a collaboration of the School of Medicine and the Bloomberg School, where it is housed, Kirsch oversees grant-funded research projects aimed at finding out what goes wrong after everything goes wrong. Which is to say, Center investigators look for ways to evaluate and, ultimately, improve the quality of relief efforts and government services during refugee crises and after tragic mega-events.
It’s painstaking work. “The trouble with trying to do research is that everyone is overwhelmed by the need to respond immediately,” says Kirsch. “It’s hardly an ideal situation to investigate things. What we want to do at the Center is improve the way we collect data in the midst of that chaos.” Because “disaster science” is an emerging field of inquiry, the Center is still working to figure out how best to do that, he adds.
In search of a method for evaluating how dire situations can be rapidly improved, Kirsch and the other 20 or so Center-affiliated investigators study the effects of disaster relief months, even years, later in hope of uncovering similarities between emergency responses in far-flung nations. They also train disaster responders to take advantage of the latest knowledge.
Too often, programs devised and carried out by NGOs, governments or the United Nations don’t do enough to get people back on their feet. Experts say that many countries don’t have the “capacity”—money or human resources—to deal with mass tragedies. Many developing nations lack disaster plans that would take full advantage of coordination and logistics. Security concerns slow the flow of aid to places where it is most needed. In many cases, getting people back to work isn’t emphasized, leaving people in poverty for longer than necessary. And even when a disaster elicits an outpouring of support, much of it never ends up on the ground. For example, only 20 percent of the $10 billion pledged by individuals, groups and governments to post-earthquake Haiti has been delivered.
What’s more, the lessons learned from one disaster often aren’t remembered during subsequent catastrophes. “What we’ll see is that different groups and nations will collect post-disaster information in different ways,” Kirsch says. “The field cries out for standardization.”
“We want to be able to describe the longer-term impact on people’s lives, health and economic status,” Kirsch says. “When a disaster happens and the CNN cameras are rolling, there’s a lot of attention paid. But after the news trucks leave, people are often left homeless and jobless for years. People forget that.”
Adds Courtland Robinson, PhD ’04, an assistant professor in International Health and at the Center: “What I’m hoping we can bring to this field are measures that go beyond profiles of a population or risk assessments, measures that can give us what I call a durable solution. Each time we do this, we shouldn’t have to reinvent the wheel. We should be able to take those approaches that have been validated by research and put them to work.”
Even though an earthquake in the Caucasus hardly resembles a drought in the Horn of Africa, the range of disasters presents many of the same challenges. “We want to be able to standardize what we do while having a customizable approach built in,” adds Robinson.
The Right Questions
In the course of their research, Center faculty and students find approaches that work. In Indonesia, for example, Robinson and his colleagues continue to measure the effects of emergency aid that followed the tsunami that steamrollered the Aceh region six years ago.
They found that an NGO program designed to put people back to work cleaning up their neighborhoods in exchange for cash did much to encourage people to return to their ravaged communities, and accounted for 93 percent of their household income, on average, as they put their lives back together.
Specialization within the disaster research field also appears to have value, Robinson adds. “What we’re learning is that if you’re going to measure the effect of an emergency on a household, you use demography to determine a rate of mortality, morbidity or other things,” he says. “For food security in a crisis, you can look to the assessments of nutritionists. The next question is whether there is a set of modules we can use across disasters that would prove effective at measuring response.”
“Our purpose is to analyze the depths of a crisis and point out where the response to it may be lacking,and how it might be improved.” —Gilbert Burnham
The aim of the studies in Indonesia, as well as Haiti and Pakistan, is to find that set of comparative metrics. Investigators asked basic questions: How many people died following a disaster? How many households were affected? How many meals has each household eaten during an average day? How did the catastrophe affect a family’s finances and ability to earn a living?
Using cluster surveys, demography and other tools, scientists mine the surviving population for information that points up when help was made available and when it wasn’t, and whether people feel their needs have been served overall. In Haiti, for example, early results from a January study of households show that people there are greatly disappointed in the quality of relief services.
Others at the Center have continued years-long investigative stretches in war-torn areas, including Afghanistan and Iraq, and seven nations in East Africa that are regularly inundated by floods and landslides. In those countries, their work has led to concrete recommendations. A handful of doctors and public health scientists track disaster and response efforts in Japan, Singapore and South Korea, or examine food aid strategies in South Sudan, or monitor outflows of refugees from starved North Korea into China, or work on ways to improve the health and household economies of Iraqi refugees and displaced people in Jordan and Lebanon, as well as Gaza and the West Bank.
The Center has also helped educate disaster relief workers and planners. The School of Public Health and the Center authored The Johns Hopkins Red Cross Red Crescent Public Health Guide in Emergencies, now in its second edition. An ongoing program—Health Emergencies in Large Populations, or HELP—run by the Bloomberg School in conjunction with the International Federation of the Red Cross, has trained 500 people from a variety of countries and universities in the latest disaster response techniques, as well as in relief planning and handling refugee crises.
Although Kirsch and others will visit disaster-stricken areas right after an event hits, the Center does not function as an emergency responder, notes Gilbert Burnham, MD, PhD, MS, an International Health professor and Center co-director. “Our purpose is to analyze the depths of a crisis and point out where the response to it may be lacking, and how it might be improved,” he says.
The Center was founded in 2004 with the merger of separate programs—each run jointly by Kirsch and Burnham—at the schools of Medicine and Public Health. Since then, it has grown markedly. Before 1998, when Burnham began his own group within the School of Public Health, “there was little in Baltimore that dealt with refugees and disasters, even though our students were very interested,” says Burnham.
“We knew we needed to grow something like the Center because some students see working internationally with refugees or during disasters as a major part of their careers,” he says. “Then there are other students who know they’ll need to learn something about working overseas in general. And there’s a third group that has already been overseas, and [the students] were floored by what they saw and need to understand it more before they go back.”
Kirsch himself became drawn to disaster scenes at an early age. (When a tornado hit Omaha in 1975, Kirsch, then in high school there, joined the response efforts.) His interest continued as he pursued his MD. “Like any medical student, I wanted to save the world, so when I had the chance to work in Cambodian refugee camps in 1984, I jumped at it,” Kirsch says.
He returned to the U.S. to get his MPH at the School, steered there by James Cobey, MPH ’71, who had organized the Red Cross’ refugee relief efforts along the Thai-Cambodian border (and who still teaches in the HELP course). “Jim told me, ‘If you want to do this kind of work, you have to go to Hopkins,’” Kirsch recalls. In 1986, he took a seminar course put together by Melvyn Thorne, a School of Public Health professor and former Peace Corps doctor. “The students literally met in his living room,” Kirsch remembers. “It was one of the first attempts to quantify and teach refugee response from a public health perspective—I mean anywhere, not just Hopkins.”
The type of work the Center does is still rarely found in academia. Governments mostly welcome Center researchers—even despotic leaders want to appear competent in the eyes of the public during times of distress, Burnham says. To grease the skids, Center faculty will often arrange partnerships with government agencies to help them set up and run their research programs. Not that they’re always greeted with open arms.
“We have had staff questioned by authorities,” Robinson says of his work in China interviewing traumatized North Korean refugees. “We tell them we’re working with vulnerable populations.” China shut down data collection during the 2008 Summer Olympics. When such edicts are handed down to researchers, they have to do their work under the radar, Robinson says: “You have to hide in plain sight.”
Elsewhere, their work has spun into controversy. Burnham’s 2006 study that pinned the numbers of Iraqi civilian war deaths during the U.S. occupation at 655,000, published in the British journal The Lancet, became a political football among those defending U.S. policies. His work in Iraq since then has focused on health care systems.
“Our intention is not to get into the political side but to improve situations,” he says. Burnham’s team investigated the effects of the war on social sciences and medicine to see whether they were recovering from the war. The team found that 29 percent of Iraq’s medical specialists had left the country during 2006.
“Many had left because of assassination attempts,” Burnham says. “If you want to destabilize a country, you go after the intellectuals.” Fortunately, the situation is now looking slightly better in 2011, he adds.
The same can’t be said for Afghanistan, which Burnham calls “an ongoing humanitarian disaster.” Relief workers and disaster researchers around the world can’t do anything to shore up dicey political situations, Burnham notes. But they believe they can learn enough to prevent some types of catastrophes, or at least minimize how many people are affected by them and for how long.
He and a small team of International Health department scientists, supported by 90 full-time workers on the ground, have tracked the performance of the Afghan health system for the past nine years. Some of the team’s research on water sources and diarrhea has led to the development of national water protection policies. An assessment of hospital performance speeded up hospital reform in the nation. Their work on the spread of HIV led to major changes in Afghanistan’s HIV policies.
Early Warning Systems
Although countries riven by civil strife, refugee crises or war take up much of the Center’s attention, it is well acquainted with natural disasters. A five-year Center project involving several countries in East Africa has encouraged public health professionals there to develop their own plans for local disaster preparedness and response.
“There are a lot of floods and landslides in these countries,” explains Daniela Lewy, MPH ’06, a research associate for the Center who spends part of each year in East Africa working on the project. “And they are increasing, possibly because of climate change.” Lewy and Center personnel train district-level public health practitioners to assess their country’s risk for disasters and develop action plans for dealing with them. They make sure that those practitioners, who are also teachers at public health schools, have some link to national ministries, so that government policymakers take their plans seriously.
Last spring, when landslides were scarring the faces of mountains and killing villagers in eastern Uganda’s Bududa district, Lewy’s project intersected with another one run by Shannon Doocy, PhD ’04, an assistant professor in International Health and at the Center. Students from Lewy’s East African program and others began to devise inexpensive ways to measure shifts in hillsides that could portend landslides nearby. “We taught people how far apart to place two poles on a hill,” she says. “If the [poles] move a certain distance apart, that’s a sign of instability. It’s something that local people can use.”
Doocy’s group had traveled to Uganda to see if studying the terrain could somehow foretell landslides—a lifesaving early warning system of sorts that could allow people to move to safe ground before disaster strikes. A newly developed (and decidedly higher-level) technology that utilizes geographical data taken during space shuttle missions, along with a topographical mapping scheme that was aided by global positioning satellites, allowed them to find a crack in a village hill adjacent to a camp for people displaced by another landslide. “We warned the local authorities of the risk and advised them that if there was further change in the slopes, they should move people out,” says Doocy, who adds that landslides did indeed occur nearby later.
Many who have come to study in the School of Public Health enroll in the master’s-level Health in Crisis concentration, which Doocy co-directs. But the Center’s reach extends beyond Hopkins students, thanks to the Health Emergencies in Large Populations course, run by Burnham.
Craig Jaques, now a program strategy consultant with a U.S. Department of Defense agency that prepares health professionals for disaster response, took the intensive three-week course at Hopkins during the summer of 2009. Since then, he has trained dozens of people from Southeast Asia on how to construct health and medical programs during an emergency—including lessons he learned during his time at Hopkins.
“The HELP course broadened my views on the international response to disasters and got me thinking about how to deal with public health concerns,” Jaques says.
Now he regularly teaches other HELP alumni. “They utilize the course’s tools and knowledge to train others," he adds. "They respond with confidence to health emergencies.” Recent HELP graduates have gone on to devise health systems in strife-torn Somalia, develop preventive health programs in rural Pakistan and run HIV programs in South Sudan.
Yet others, like Paul Perrin, a doctoral candidate in International Health, come to the School to study so that they can continue their work amid disasters. Perrin, formerly a missionary for the Mormon Church, began disaster work when he was 19, helping victims of an Armenian earthquake.
Now 30, Perrin believes he and others are on the cusp of some exciting findings. “It’s a young field,” he says. “Most of the research done by NGOs isn’t robust because they measure their own idea of success. They’ll ask people who get their services what they think of their work but often don’t do the same for those who haven’t. They don’t use population-based methodologies. That’s the strength of what Hopkins does.”
Biostatistics and epidemiology classes give students a broad knowledge base with which to construct studies and work them out in the field, he adds. “Hopkins teaches you that this is a scientific discipline above all, one that takes a hard look at individual disasters and how they are dealt with.”
In Haiti, Perrin personally trained locals to do interviews in the field, overcoming a language barrier (he doesn’t speak Creole). He says that gathering such data from the 60 sites that Center personnel systematically chose is vital in improving NGO performance. “I suspect many relief groups think we’re looking over their shoulders, but I also think they’ll be very interested in our findings,” he says. “When you get down to it, they really want to do the right thing.”