During the war in Afghanistan, the mil­i­tary decid­ed to air drop food pack­ages as part of its win­ning hearts and minds cam­paign.

Unfortunately, the food pack­ages were very sim­i­lar in appear­ance to the clus­ter bombs they were drop­ping at the same time. If mil­i­tary decision-makers had spo­ken to com­mu­ni­ties, aid work­ers, mil­i­tary per­son­nel on the ground, they’d have fig­ured out there were smarter ways to deliv­er food and win the trust of the Afghan peo­ple. Listening to those who live a par­tic­u­lar prob­lem is essen­tial to effec­tive pol­i­cy. I’m gonna explain why using two exam­ples. First, the ebo­la out­break in West Africa which began in 2014.

Ebola is not a par­tic­u­lar­ly con­ta­gious dis­ease. If those who become sick or die of the dis­ease are cared for safe­ly and buried safe­ly, you can stop its spread. It’s how we’ve dealt with ebo­la in the past, and it was it’s how in the end we con­trolled this par­tic­u­lar out­break.

But why did it take so long and affect so many? When I arrived in Guinea ear­ly in the out­break, I was say­ing cas­es that we couldn’t link to oth­er patients. And I want to talk now about this ques­tion of lis­ten­ing and learn­ing from those who live the prob­lem.

In ebo­la, it means build­ing fences that peo­ple can see through. In the past we used seven-foot high black plas­tic sheet­ing. People couldn’t see what was going on. They thought we were doing things like eat­ing the dead—a good rea­son not to come for care. 

It also means vis­it­ing patients’ house­hold in an old blue pick­up and spend­ing two hours talk­ing to their fam­i­lies. An old blue pick­up because shiny white Land Cruisers meant you were an ebo­la home. Two hours because that’s what it takes in any sit­ting to con­vince some­one to report a dead­ly quar­an­tinable dis­ease in those they love. And final­ly, lis­ten­ing and learn­ing from those who live the prob­lem means tak­ing action.

As I said, when I arrived in Guinea, I was see­ing patients who had no oth­er con­tact with oth­er known patients. A clear sign we were miss­ing cas­es and we had lost track of the dis­ease. Those of us on the ground knew very ear­ly on that a mas­sive scale-up in response was need­ed.

It took time for those mak­ing deci­sions to hear us. Resources went into man­ag­ing polit­i­cal risk rather than man­ag­ing the dis­ease. And in the months it took to hear us, the cost of the out­break and of its con­trol increased astro­nom­i­cal­ly.

Ebola was one exam­ple. The oth­er I’m going to speak about is some­thing per­haps even more com­plex, gender-based vio­lence. We do a lot to mea­sure the prob­lem now, a lot more, but we still invest very lit­tle in eval­u­at­ing solu­tions. The area, and par­tic­u­lar­ly in low-resource set­tings, and the area we have least evi­dence for, is how to help those already in the cycle of vio­lence. We need not just to mea­sure but to do, and learn from that doing in a range of set­tings.

A few years ago, we eval­u­at­ed a health ser­vice for sur­vivors of gender-based vio­lence in Papua New Guinea, one of the highest-prevalence set­tings in the world for this par­tic­u­lar prob­lem.

The thou­sands of women and chil­dren who came to the ser­vice each year proved that if you pro­vide free, acces­si­ble, high-quality care, many would come—something peo­ple didn’t think in the past. Almost all of those sur­vivors that were com­ing to that clin­ic knew the per­son who was abus­ing them.

Many, par­tic­u­lar­ly those affect­ed by inti­mate part­ner vio­lence, would stop com­ing to the ser­vice after one coun­sel­ing ses­sion. They were telling us that they didn’t want help feel­ing bet­ter or accept­ing abuse in their sit­u­a­tion, they want­ed sup­port to change it. The nurs­es who worked in that clin­ic were using their own salaries to give women things like bus fare to escape abuse.

So work­ing with these staff who’d seen the prob­lem and found their own solu­tions, we start­ed a cri­sis sup­port ser­vice. In the two years that that’s been oper­a­tional, it’s seen over a thou­sand sur­vivors, and it’s helped them access emer­gency accom­mo­da­tion, police, court, and oth­er ser­vices. What we’ve learned in that time is that achiev­ing safe­ty and jus­tice is pos­si­ble, but it can take years and it requires inter­ven­tions that link com­mu­ni­ties to effec­tive ser­vices.

Building on this knowl­edge, we’re now start­ing a ran­dom­ized con­trolled tri­al in Sri Lanka. Its test­ing low-cost solu­tions the com­mu­ni­ty them­selves have devel­oped to address the prob­lem of domes­tic vio­lence.

Listening and learn­ing from those who live a prob­lem is essen­tial to effec­tive pol­i­cy. It doesn’t cost more. It doesn’t waste time. It’s the best, most effi­cient way of iden­ti­fy­ing promis­ing solu­tions to com­plex prob­lems. And in the end it’s the only way we will know whether they work in the real world. Thank you.

Further Reference

How Ebola Roared Back, Kamalini Lokuge, New York Times


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