Definition and Background
In the fall of 2017, a series of hurricanes ripped through the Atlantic, leaving much of the Caribbean and areas of the southeastern United States absolutely battered. As news of the devastation spread rapidly through the global media, desperate cries for help among the worn communities became louder, and, like with most contemporary catastrophes, the global disaster relief machine was set in motion (Garfield, 2017). Disaster relief is, generally, the organized humanitarian economic, social, and material aid provided to communities in the aftermath of some sort of crisis, or “a general sense of rupture that demands a decisive response” including natural disasters, political upheaval, medical emergencies, and other cataclysmic situations (Redfield, 2005, p. 328). Disasters, specifically defined by the World Health Organization (WHO) as “event[s] that kill 10 or more people or leave 100 or more injured, homeless, or displaced,” are often very complex situations affected by and affecting a multitude of factors like “civil strife or war, food shortages, and population displacement” that often exacerbate each other and thus necessitate a more multifaceted, layered response from the international community (Benjamin, Bassily-Marcus, Babu, Silver, & Marin, 2011, p. 307).
These disaster relief efforts may be initiated by individual donors, non-governmental organizations (NGOs) such as Doctors Without Borders (also known as Médecins Sans Frontiéres, or MSF), or state-sanctioned departments such as the U.S.’s Federal Emergency Management Agency (FEMA), and they provide a variety of services in locales across the globe. Actual aid provided varies by context and need but may include distributing clean water, assisting local healthcare facilities combat an infectious disease, or managing refugee camps. Although the underlying rationale or philosophy of disaster relief is a “humanitarian desire to alleviate the suffering of others,” it is a field fraught with social, ethical, and political criticism centered around questions of biopolitics, otherizing, and (lack of) cultural humility (Redfield, 2005, p. 330).
Historical Perspective
Historically speaking, disaster relief organizations and efforts become more institutionalized post-World War II as the “development of [an] emergency specialty [evolved] out of a military specialty” amidst the convergence of other factors like “decolonization, improved systems of air transport, and the emergence of global media” that made large scale crises more visible and accessible (Redfield, 2005, p. 331). WHO maintains a record, the Emergency Events Database (EM-DAT), which catalogues the frequency and consequences of disasters around the world. Since 1900, the EM-DAT has detailed over 18,000 different events and reports that the number is increasing annually. (Benjamin et al., 2011, p. 307). It seems that “rupture is more central to modern order than we frequently choose to remember,” and if these disasters are to be dealt with optimal efficacy, efficiency, and justice, more evaluation and discourse is desperately needed (Redfield, 2005, p. 329).
Controversies
One of the most central dilemmas surrounding disaster relief organizations and efforts is deciding which disasters are most worthy of aid. Oftentimes, “the size, length, and duration of these [disasters] as media events reflect their relative rank within an order of official valuation” which often requires someone deciding which group of people is in the most need (Redfield, 2005, p. 336). This triage process occurs at both a macro level when deciding which site or community to deploy to and at a micro level when deciding which individuals to give limited food supplies to or allow into the tent with volunteer trauma surgeons. Ultimately, when deciding who receives aid, the arbiters of relief exercise a sort of God-like sovereignty over life and death when they choose which disasters most warrant a response. In other words, when a relief organization makes the decision on which disaster most warrants their assistance, the organization is using some type of value or judgment system that places the survival of one group of people over another. These decisions are necessary, but it is the rationale behind these decisions (i.e. how to decide which people most likely live and which most likely die) that should be further scrutinized (Redfield, 2005, p. 344).
In many emergency rooms, the prevailing rationale behind triage can be traced back to the traditional 1790s-era understanding of just treating the sickest individuals (or communities) first and with the most resources (Adler, McEwen, & Fink, 2016). In the midst of disaster relief efforts, however, the thinking is usually more utilitarian as responders try to maximize the best outcome for the population as a whole. Sheri Fink, journalist for the New York Times, spent months researching and reporting from the frontlines of disaster relief in places like Bosnia, Haiti, and New Orleans, and as she discovered, in practice, these triage decisions are inherently messy and controversial (Adler et al., 2016).
In New Orleans’ crowded, overheated Memorial Medical Center after Hurricane Katrina in 2005, hospital personnel used a system ranking patients on a 1-3 scale, with one representing the healthiest and easiest to transport; these patients were designated priority and were the first to be saved from the rising floodwaters. Relief workers later reported on the duress of making decisions on, effectively, who most deserves help. It’s impossible to not make these decisions, but deciding how to make them is hotly contested: “in these extreme moments when life and death are wrestling with each other, can you make rules?” (Adler et al, 2016, 58:20). Allocating justice (i.e. choosing who most deserves relief) in a world of disasters is a sticky process, and one in which someone will almost always feel left out. Unfortunately, “rationing triage…is an inhuman act which humans are trying to do, but the fact of their humanity makes it impossible;” not everyone can be saved (Adler et al., 2016, 1:0050-1:01:02).
Even further, when patients are under serious threat of death and often without formal medical records or familial support available, there exists “the question of ethical appropriateness of…nonconsented interventions under utterly chaotic conditions” (Benjamin et al., 2011, p. 311). Informed consent is often lacking, and relief personnel are forced to exercise their best judgment, easily fraught by bias, stress, or lack of expertise. One of those New Orleans doctors, Anna Pou, came under investigation for allegedly euthanizing multiple patients without any kind of informed consent or legal permission. The Louisiana Attorney General charged her with both second-degree murder and conspiracy to commit second-degree murder, but the convened grand jury decided to not pursue indictment, thereby effectively squashing the criminal case against her (Bailey, 2010). Although eventually declared innocent, the investigation prompted discourse around informed consent in the midst of chaotic disaster relief efforts (Adler et al, 2016).
Furthermore, disaster relief is not always so simple to access. Especially when referring to aid provided by governments, the actual provision of supplies, medical assistance, and other services is the last step in a lengthy, bureaucratic process. For instance, FEMA, the emergency management department of the U.S. federal government, only is authorized to provide aid after a formal disaster declaration is requested by a state governor, formally assessed by FEMA officials, and then approved by the president; between 1953 and 2009, 729 of 2,363 total requests were denied, and the victims of those various “disasters” (often floods) were forced to look for assistance elsewhere (Kousky & Shabman, 2012).
The Challenge of Triage: One of the hospital personnel at New Orleans’ Memorial Medical Center who was tasked with deciding which patients should be saved first. (Lopez, 2016)
Connection to Politics of Health
Disaster relief efforts can be even more directly related to politics of health in terms of notable social theorist Michel Foucalt’s theory of biopower, or the idea that “facts of existence related to bodies and populations could become the focus of specific operations of government” (Redfield, 2005, p. 339; Foucault, 1978). In other words, as disaster relief becomes institutionalized (i.e. through the formalized organization of more NGOs, government agencies, etc), the state, or other formal sources of influence, gain more authority over, essentially, survival. Even if unintentionally, large-scale relief efforts are more oriented towards promoting survival in itself-purely a base form of existence-rather than a reestablishment of full-fledged life, health, or community. The victims are reduced to abstract figures, and “human zoology exceeds biography: those whose dignity and citizenship is most in question find their crucial measurements taken in calories rather than in the ability to voice individual opinions or perform acts of civic virtue” (Redfield, 2005, p. 344, 342). These victims are thus socially displaced too, occupying “ a lower threshold of human possibility: ‘bare’ life, or a form of naked existence without any benefits of social being whose death…can occur without recognition of loss” (Redfield, 2005, p. 340). Although they are allowed to live, many individuals are stripped of the very dignity and opportunity many relief efforts purport to be restoring. It is quite a “haunting possibility of a form of distinction enacted within life itself that simultaneously includes and excludes different human populations at the species level” (Redfield, 2005, p. 330). Biology and survival are, more and more, becoming powers of the state which leads back to the question of who should be saved.
Bodies vs Citizens: Link to footage of a Doctors Without Borders run refugee camp in Endebess, Kenya. (MSF, 2008)
Another concept important in studying disaster relief efforts is cultural humility, or an approach to working with other cultures and communities that values “self-evaluation and self critique,…redressing power imbalances…and developing mutually beneficial and nonpaternalistic…partnerships” (Benjamin, 2016, 978). Originally conceptualized in regards to the patient-provider relationship, the term can be expanded to the larger scale of disaster relief (Campinha-Bacote, 2002).
Often, however, aid is condemned for its lack of this humility. While often doing much short-term good, relief workers may be criticized for having a post-colonial influenced White-Savior Industrial Complex and letting inflating egos come before achieving real change (Cole, 2012). Furthermore, workers may go into a devastated area and take over, creating a broken cycle of dependence and perpetuating existing inequities. Many disasters stem from “serious problems of governance, of infrastructure, of democracy, and of law and order…[that] are both intricate and intensely local” (Cole, 2012, p. 1). Effectively providing relief requires not only an understanding of the community, its members, and a clear, nuanced understanding of the problem, but also a “respect for the agency of the people” in need (Cole, 2012, p.1). If the community is not somewhat involved in the strategic planning and distribution of relief, they are at the risk of continuing to be understood, by themselves and others, as victims being herded to aid instead of knowledgeable stakeholders in the process of restoration: a community can be aided by the outside, but ultimately, they often know what they need best (Zakus & Lysack, 1998).
One small example of the value of working with instead of for a community comes from Victor Marchezini‘s (2015) fieldwork and research on the biopolitics of disaster. During a Brazilian firestorm in 1991, external agents who had come to aid were “confident in their competence” of navigating a local river during rescue efforts, refused the help of locals who knew the area far better, subsequently capsized their boats and required rescue themselves (Marchezini, 2015, p. 365). However, disaster relief is not supposed to be a cure-all for all physical, economic, and social ills; instead, “it is an immediate, short term act that cannot erase the long-term necessity of political responsibility” (Redfield, 2005, p. 336). Humanitarianism should be a stabilizing force that sparks political change but does not directly lead the charge.
Disaster relief can do much good in areas that are war torn, physically decimated, or otherwise incapacitated, but the work has also been criticized as being “haphazard in organization, largely symbolic in impact, full of romantic panache, and entirely temporary in duration” (Redfield, 2005, p. 333). Clearly, there is not one clear way to provide aid. Besides, “even critics of humanitarianism rarely embrace openly antihumanitarian alternatives, such as the conscious sacrifice of individuals or populations for material or political gain” (Redfield, 2005, p. 348). It is not about replacing the process, but about improving it so that all distressed communities receive the most quality and beneficial aid possible in the face of unfathomable tragedy.
References
Adler, S., McEwen, A., & Fink, S. (2016 August 21). Playing God. Radiolab. Podcast retrieved from http://www.radiolab.org/story/playing-god/
Bailey, R. (2010). The case of Dr. Anna Pou-Physician liability in emergency situations. American Medical Association Journal of Ethics, 12, 726-730.
Benjamin, E., Bassily-Marcus, A., Babu, E., Silver, L., & Marin, M. (2011). Principles and practice of disaster relief lessons from Haiti. Mount Sinai Journal of Medicine, 78, 306-318.
Benjamin, R. (2016). Informed refusal: Toward a justice-based bioethics. Science, Technology, and Human Values, 41, 967-990.
Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13, 181-184.
Cole, T. (2012 March 21). The white-savior industrial complex. The Atlantic. Retrieved from https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/
Foucault, M. (1978). The history of sexuality. New York: Pantheon Books.
Garfield, L. (2017 September 23). The best charities to give to for victims of hurricanes Harvey, Irma, and Maria. Business Insider, Retrieved from http://www.businessinsider.com/best-charities-to-help-hurricane-victims-harvey-irma-maria-2017-9/#hurricanes-maria-and-irma-local-organizations-in-puerto-rico-1
Kousky, C., & Shabman, L. (2012). The realities of federal disaster aid. Resources for the Future, 12, 1-16.
Marchezini, V. (2015). The biopolitics of disaster: Power, discourses, and practices. Human Organization, 74, 362-371.
Medecins Sans Frontieres. (2008 June 16). Setting up the Endebess displaced peoples camp, Kenya. Retrieved from https://www.youtube.com/watch?v=bsoku8RkTfU
Lopez, B. (2016, August 21). [Nurse fanning patient.]. Retrieved September 24, 2017, from https://www.nytimes.com/2016/08/22/us/whose-lives-should-be-saved-to-help-shape-policy-researchers-in-maryland-ask-the-public.html
Redfield, P. (2005). Doctors, borders, and life in crisis. Cultural Anthropology, 20, 328-361.
Zakus, J.D., & Lysack, C. L. (1998). Revisiting community participation. Health Policy and Planning, 13, 1-12.
« Back to Glossary Index