Mounting conflict and the effects of climate change mean displacement and migration show no sign of slowing. The front line of health, the last mile, no longer looks the same. It can be a refugee camp, the roadside, or an underresourced clinic in a fragile or war-ravaged setting. Building resilient health systems equipped to withstand changing environments has never been more urgent. There are certain steps to putting adequate systems in place for quality care that are now needed, as programs need to be integrated to move beyond physical health toward mental health and other needs.
“One of the things that you have to ask in a situation like the Syrian refugee crisis, and its effect on surrounding nations, is whether this is a temporary or a long-term situation? And what are the right things needed to deal with the influx, pressures, and challenges in the short-, medium-, and long-term?” said Ben Davies, Europe, Middle East and Africa lead at Johnson & Johnson Global Community Impact. “That is when the question around last mile health comes into focus.”
Sitting down with Devex, Davies explained why organizations need to think beyond immediate support in humanitarian contexts in order to bolster health systems in the long-term — and why local contingencies need to be considered, too.
“Sometimes, the majority of support goes to humanitarian response — and that's correct, but when the media and the news cameras move elsewhere, it becomes a rather forgotten situation,” he said.
This conversation has been edited for length and clarity.
As the world's population continues to migrate due to conflict and the adverse effects of climate change, what does last mile health look like?
Climate change’s impact on migration is multifaceted and complex because there are politics, economics, and people involved. There have been phenomenal stress points put on the health system, specifically in countries of conflict because of that disruption, but also in neighboring countries or countries along a migratory route. Take the situation in Lebanon, Jordan, Turkey, neighbors to Syria. The demographics of each country have changed. You can imagine any given country with a major influx of people, irrespective of where the people come from, has to deal with tremendous stress on an education system, a health system, or any given system.
How do you ensure that there's access to basic services for the new influx of migrants without compromising on services for local communities? They're very much part of that system, too.
What does a resilient health system look like?
First, it requires effective primary care in terms of outreach into communities. There has been a tendency to focus on urban settings. One of the biggest myths in the world around migration is that all refugees live in camps. In Lebanon, 90 percent or more do not live in any organized camp. In reality, local communities manage the influx. The base of community care and primary care needs to flow into a system that is working from a secondary and tertiary perspective.
“Investing in the capacity of the health workforce does have immediate returns for the people in these communities, but it also has long-term impact.”— Ben Davies, Europe, Middle East and Africa lead, Johnson & Johnson Global Community
Another thing that is always consistent is the multidimensional aspect of the problem. From a conflict perspective, there is physical trauma that is more easily picked up on — an injury or an amputation can be seen easily. Immediate, physical needs are services that post-conflict health providers are better equipped to address.
But the most underestimated health condition in post-traumatic setting is mental health. Underestimating mental health can lead very quickly to a downgrade of physical health. Care for one must work very closely with the other. That is one of the bigger gaps.
The people you are serving in these contexts have had their entire lives affected. That’s when traditional primary care intersects with secondary and tertiary care, but it also has to deal with hidden issues.
Take stigma — this is still deeply attached to mental health care, even in a post-conflict setting or a traumatic setting. We have to ask ourselves, “what are the right skills to diagnose and care for the visible and invisible effects of conflict?” Having the right people deployed in the right place at the right time is one of the cornerstones of an adaptive and human-centered working system, but it remains a major challenge.
How can early childhood care and development be provided for in areas affected by conflict?
Improving the lives of children can have a dramatic effect on the health of whole communities, something many of our partner organizations are focused on. Let’s use the Syrian context again. Our partners are able to support in early childhood development by delivering safe spaces for children to develop cognitive and physical learning abilities. There should always be a safe space where children can still be children. I believe this to be critically important.
It might seem out of place in a context of conflict to have this kind of space when attention goes to food, shelter, sanitary issues, and basic first aid. But let's not forget that these situations remain highly volatile and, in some cases, people might be displaced for several years. That’s why providing consistent space for children to still be children is so important to establish early and retain.
What programs are in place to continue care once in a stable environment?
This is an important question and one that we, at J&J, looked at early on when evaluating what our response should be after responding to the immediate humanitarian crisis [in Syria].
We engaged a number of different key opinion leaders — beyond our partners to people with good insight into the situation — to see where we could best invest funds and leverage capacity from J&J to support the overall situation. What transpired very quickly was that we should influence two particular areas: Early childhood development with a specific angle of psychosocial support, and support around trauma.
We created an alliance with Save the Children and the National Pediatric Associations in Lebanon, Turkey, and Jordan under the umbrella of the International Pediatric Association Foundation. Building capacity of the local health workforce responding to this enduring crisis, in collaboration with NGOs such as Save the Children, helps support and champion the people on the front lines of delivering care.
Who are the best people to support, from a psychosocial perspective, and are there enough of them? No. Are there enough trained psychiatrists? No. Our partnership learned quickly that we had to be able to spread this sort of training quickly and sustainably. We invoked the “train the trainer” method. Led by Save the Children, our partnership has brought increased capacity to provide care while combining training with local professionals. By operating in surrounding countries, there is ongoing mental health support, which creates a ripple effect of knowledge transfer in mental health care.
Investing in the capacity of the health workforce does have immediate returns for the people in these communities, but it also has long-term impact.
Increasing the skills and leadership capacity of national associations means improving the lives of local people who will be managing the effects of this conflict in the long term — that's their livelihood, that's this community and where they work on a daily basis.
That’s why J&J is invested so deeply in capacity and leadership building for those at the heart of care — they are at the heart of their communities — and why, as a global company, J&J believes in the impact one person can have on health for humanity.
It may seem hyper-local, but we believe that’s where global change in health begins.