Humanitarians working on health in crisis situations are faced with constant difficult choices. In a famine, which children should they select for supplementary feeding? In an earthquake, should they try to save most crushed limbs or should they amputate them? And - inevitably - what is the best way of spending scarce funds? Should they spend directly on health care, or indirectly on water, sanitation and shelter to prevent disease?
They choose as best they can, based on common sense and experience, and on their own agencies' guidelines, but there is often little hard evidence of which interventions work best. Now a new funding programme, Research for Health in Humanitarian Crises, is putting up a pot of money for research which will strengthen the evidence base for these decisions.
“This field of humanitarian crises is a field where there really is a very limited evidence base,” said Jimmy Whitworth of the Wellcome Trust, which is co-funding the initiative along with Britain's international development ministry, DFID. “This is tough stuff to do. To collect evidence in the face of disaster where there are many imperatives and many reasons to be acting very fast is hard, and people have been struggling to do this.”
But DFID and the Wellcome Trust feel it needs to be done. “What we know from all areas,” said DFID chief scientific adviser Christopher Whitty, “is that if you are doing something without a good evidence base, probably most of what you are doing is pointless, some of it’s harmful, and at best a lot of it won’t be very cost effective.”
Chairing the committee which will be selecting the projects is Paul Spiegel, who has a foot in both academic and humanitarian camps, as an adjunct professor at Johns Hopkins School of Public Health, and deputy director of programme support at the UN Refugee Agency (UNHCR). He has just returned from Jordan, Lebanon and Iraq and says there are lots of questions which need an answer.
“Most of the research in the past has been in low-income, camp settings. But now in the last while, in the Balkans, Kosovo and now Syria, we are dealing with middle-income, non-camp situations. In Lebanon now, a quarter of the population are refugees. So there are a lot of questions that came up. How do we work differently?”
The initial funding is for US$9.5 million spread over three years. The programme envisages two funding rounds, each of which could support 10-15 targeted projects, ideally collaborative research involving both academic and humanitarian communities.
The programme also intends to establish a rapid response facility which would allow pre-approved research projects to be set up, ready to go in the acute phase of future emergencies.
To many of those attending the launch of the scheme, $9.5 million sounded like a fairly modest level of funding, but they acknowledge that it is not always the most lavishly funded research projects which turn up the most influential results. Mark van Ommeren, a scientist at the World Health Organization, told IRIN: “This is a fantastic start, and I think the funding will increase over time.”
The Wellcome Trust's Jimmy Whitworth confirmed that the present level of funding could change. “This is a bit of a toe in the water, or a finger in the air, if you like. We don't know what the appetite will be for this.
Plenty of organizations came to the launch with applications ready in their back pockets.
Managing crush injuries
Anthony Redmond of Manchester University is looking for evidence about the best way to manage crush injuries after earthquakes. You can try to save the limb, which is time consuming and expensive, and if unsuccessful can put the patient at risk of death from infection or kidney failure. Or you can amputate and leave the patient disabled in what may be very challenging circumstances. Some emergency medical teams amputate a lot, some very seldom. And emergency teams aren’t usually around to see what happens to their patients later.
“There is a window of opportunity to save limbs,” Redmond told IRIN, “But I don’t know how wide that window of opportunity is. What is the point of no return? How much should you try to salvage one limb in one person as against saving the lives of many people? And that’s what we need to understand.”
Redmond's research proposal would involve surgeons systematically recording data while operating in crisis conditions. Would they do it? “They do that in their home countries. If there is a plane crash here [in the UK], or a train crash, you are required to make notes. The medical note and the surgical note are part of the treatment and it is unethical not to do it. What we need to do is devise a method of collecting that data very easily and very quickly.”
Paul Spiegel's experience in UNHCR suggests this may be still a challenge. “Many of our organizations have not been prepared to do research,” he says. “Still, in my own organization we try not to use the word `research', because there is this attitude that `the money is there to help people’ - even if we don’t have the evidence to know if the money is actually helping them or not… We hope that this research will answer important questions that will guide the people in the field to make these decisions.”