WASHINGTON — Just as the scale of health care needs in crisis contexts is surging, humanitarian groups are fighting their own battle for the human resources to respond.
Organizations providing health services in the midst of humanitarian crisis are under enormous pressure. Increased displacement, a dwindling health workforce, attacks on health facilities, and tighter regulatory requirements have combined to create an extremely challenging working environment.
Devex spoke to Esperanza Martinez, head of health at the International Committee of the Red Cross, about how the humanitarian sector is taking a proactive approach to building the health humanitarian workforce of the future — one that is fit for purpose in a world presenting unprecedented demands.
This interview has been edited for length and clarity.
So many disasters now are driven by conflict, and so many of those conflicts are occurring with less respect to international humanitarian law. Are those factors changing the nature of the humanitarian health care provider’s profession, and therefore the nature of the skills that people need to do the job?
We are in a world that is much more polarized, is much more radicalized. The gap between rich and poor is becoming wider. Those issues are creating social dynamics that lead to more conflict. So, because of conflict, on either acute conflict or protracted conflict, we expect a larger number of humanitarian needs.
On the other hand, you have a shift in migratory policies. Today there is an environment in which displaced communities, or refugees, are less welcome, and therefore there is a big push to keep them in their places of origin. The consequence you are going to have is bigger humanitarian needs in those places — either in the transit locations or in the places of origin. You also have the issue of high human mobility, which means that today you have an outbreak in Africa, and tomorrow it might be at the doorstep of the United States. This very fast-moving spread of diseases means that we need to respond very quickly to a potential humanitarian crisis.
Then you have also an issue of global warming and droughts and floods, and that changes the economic situation in many communities for millions, particularly in Africa. If we look at the global situation today, we see that there are all the perfect elements to make the humanitarian crises even more numerous with a larger number of people affected.
In the middle of that, you have a shortage of health care workers worldwide. That's a phenomenon the [World Health Organization] is addressing through different task forces. It's a phenomenon that is not only affecting developed nations, but also developing nations, and it's affecting the humanitarian sector, and we feel it. Joined to that is the fact that there are less and less generalists. So, today you have surgeons that come out of university and straightaway go to a specialization. When you are in the humanitarian field, particularly in conflict areas, you cannot bring an orthopedic surgeon, plus an [obstetrician-gynecologist]. You have to bring one [person] that is able to do all the lifesaving operations — [but] they don't exist anymore. They are not being produced by universities anymore. The same thing happens with medical doctors, with nurses and so on. This early specialization is really shrinking the workforce of generalists available for humanitarian action.
There is an increased level of competition, as well, between agencies to try to keep the most experienced delegates. You have an environment with a larger volume of humanitarian needs, and at the same time you have a shrinking workforce, both because of numbers and because of skills.
“We need to be more proactive. We can't keep waiting for universities, or for a single university, or a single country to produce these humanitarian workers.”— Esperanza Martinez, head of health at ICRC
And if that was not enough, we have an increased regulatory framework. Today you cannot just say, “yes we deliver services.” It's now to whom? For how long? And if you are delivering pharmaceuticals, you have to make sure that all the line of supply is [tracked] to the last minute. The regulatory frameworks are stronger, which means that we need to deliver services in a more professionalized way as well.
That sounds like the only good thing that you've mentioned so far.
This is actually positive, but at the same time it means that we need experienced delegates. We cannot send people with no experience. The quality frameworks are very, very fixed. It's fantastic, because they allow us to provide better quality to the populations we serve. But at the same time, it means that the workforce, which is scarce, less available, needs also to be very well trained. How do you deal with that? That's where we are today. We are basically in an environment where we have less health care workers, but we need them also, the few available, very well trained and able to do a little bit of everything within the regulatory framework.
I think somehow we need to be more proactive. We can't keep waiting for universities, or for a single university, or a single country to produce these humanitarian workers. We need to establish partnerships to see how we can have an active role in training them, in making sure that they do have the skills, producing generalists.
Is the hope that in the future there will be more medical students training to be humanitarian health providers?
Let's say I am a student of medicine, I am in my last year, and I am interested in dedicating a few years of my life. Then there is a program that tells me, okay you want to do that, then these are the skills you need. You will need to have skills for project management, and then you will have to have some basic leadership skills. Some of that knowledge could be acquired prior to graduation. Then we, as the main humanitarian agencies, have the responsibility to provide an environment where they can be exposed and acquire the practical skills. Let's say someone is a general surgeon, a trauma surgeon and says, “I would like to do some humanitarian work” — to be able to have within the university or the academic center the possibility of doing a [work]stream on humanitarian surgery or global surgery.
I think the win-win situation here is if we manage to organize that, it will not only be useful for the humanitarian environment, but it will be useful for those countries of origin of those professionals. When they come back they have sets of skills that are becoming relevant today — with highly insecure environments, the fact that we have security situations now in urban populated areas that are subjected to complex attacks. You have a workforce within your own city that already is familiar with dealing with a trauma, war-like situation. Then you are more equipped as a health system in your own country of origin to deal with that. We are looking at that from the humanitarian perspective, and the academic partners are looking from the development perspective of their own workforce. But again, it will require cooperation. This is way too big for one organization to do it alone.
So you're at the beginning of this process?
We are at the very beginning. Each one of us, each organization, has advanced a lot. The academic centers have already advanced a lot on training curriculum, already are doing pilot projects in different countries. We have training on war surgery and security training prior to deployment in the field. Médecins Sans Frontières already has their own training programs. The idea is: Can we put it all together, rather than doing one by one? Can we join efforts and try to do this at a bigger scale? I don't think it's reinventing the wheel or creating anything new. But it's really joining efforts to see if we can produce something more impactful.
In addition to these issues of the humanitarian health workforce, how is the current context of conflict-driven crises changing the type of skills and the nature of professionals that need to be deployed?
During the humanitarian emergency of 2017 in Mosul, Iraq, the World Health Organization created a referral chain for trauma victims of the fighting — including soldiers from the frontlines. The move saved hundreds of lives, but has come under criticism from some NGOs who say it risked blurring the lines between humanitarianism and taking a too active role in a conflict.
I think one element that I would highlight is the understanding of international humanitarian law and principled approaches in conflict. It's very easy to think that in conflict you just basically deploy, and operate, and perform surgery, and then you're pulled out. Health care workers do have a duty in relation to protection of patients, in relation to not only delivering impartial care as health care workers, but that the operations are perceived as impartial, and that people have access [to care] without feeling that they [must belong] to one specific party to a conflict.
We as the ICRC play a key role in further dissemination of principled approaches and particularly the element of international humanitarian law and protection of the population, but also the obligations of parties to the conflict.
That surprises me a little bit, because I've never heard the point that it's the humanitarian groups that need to bolster their knowledge of international humanitarian law. I've always heard that it's the parties to the conflict who are negligent.
“Imagine you are a doctor in a hospital and someone walks in with a weapon and threatens you. How do you handle that?”—
But I think everyone plays a role. We have this project called the Health Care in Danger project, which is basically arguing for the protection of medical infrastructure, personnel, and transport services. Of course, under IHL that’s an obligation to the parties to the conflict. But then imagine you are a doctor in a hospital and someone walks in with a weapon and threatens you. How do you handle that? How do you know that under the law, that person shouldn't be walking with a weapon into your hospital? He's meant to know, she's meant to know, but you are also meant to know, because then you have the possibility, when it is right there of saying, “You know what? You shouldn't be doing this. I am at the moment treating my patients, and they could be your relatives. There is a reason behind the protection of these facilities, and you cannot enter like that.”
If we provide those tools as well to help personnel in conflict settings, we have multipliers that can really make a difference. We cannot reach every single group out there. We can train the armies, but today there are many irregular groups that are working and operating in conflict environments, and very often our health professionals are the ones that encounter them. Sitting at the checkpoint is a great opportunity to [spread the message that] we are protected by law, and actually we are covering a very significant amount of work. Health doesn't have corners. Health doesn't have groups and allegiances.
Where does that training happen now for people who work for ICRC? Where do they learn about international humanitarian law?
We have, prior to deployment, a staff integration program, a very intensive 10-day training on both protection, which involves international humanitarian law and the Geneva Conventions, and then the whole aspect of our assistance. No one can be deployed without having the staff integration program.
Then on top of that you have a security training course, which is basically how to deal with security issues. Additionally, there are more specific courses on international humanitarian law and on health delivery in complex settings and so on. There are different mechanisms, but those two are compulsory. So they get to learn about that, to learn that the ICRC is not an NGO, that we don't work project by project, that actually we work with the four [humanitarian] principles, not with one or two or three but all of them.
It's all of those things that need to be learned. We receive a lot of novices, but we have a lot of exchange, for example, with MSF, and MSF has a different approach. It's a humanitarian organization. It's also a principled organization, but they do approach the principles from a more medical point of view, so we need to basically brainwash a person.
In a good way.
In a fantastic way. Because then they go back to MSF and they bring with them a wealth of knowledge. We used to say that we poach people from one organization to the other. Now we say that we have two-way traffic. They go back there and they come back here. It really makes sense for us to cooperate more on all of these issues.