How often do I act without knowing whether I’ll achieve the desired outcome? I’d say fairly often when the decision will only affect me, and the stakes aren’t so high. The exact opposite is the case in situations of conflict, environmental disasters, and disease outbreaks: actions can have consequences for large numbers of people, frequently concern matters of life or death, and certainly affect quality of life and dignity in living.
This is particularly the case when it comes to health issues: as a medical practitioner, if I don’t know enough about what I’m doing, how do I know that I’m actually helping? Even more fundamental to ethical practice, how do I know I’m not actually causing harm? These challenging and deeply distressing questions were shared by many of us during the first months of the COVID-19 pandemic as the urgency to act was self-evident, the need to make morally ambiguous choices inevitable, and the evidence to inform difficult decision-making patchy at best.
These challenging situations are far from unique. During the late 1990s and early 2000s a series of failures in humanitarian response prompted a chorus of individuals and institutions to call for widespread changes across the humanitarian sector: coordination, standardisation, professionalisation and effectiveness were the buzzwords of the moment. A lack of evidence was seen as a major barrier to effective humanitarian response, with a tendency towards reporting on organisational presence and programmatic outputs as inadequate proxy measures of impact.
From gaps to remedial action
To this end, Elrha launched the Research for Health in Humanitarian Crises (R2HC) programme in 2013. The premise: better evidence leads to more ethical and effective interventions, which in turn improves health outcomes for people affected by humanitarian crises.
To determine the extent of available evidence, we commissioned the first Humanitarian Health Evidence Review in 2013 to identify published research on the effectiveness of humanitarian health interventions in lower- and middle-income countries (LMICs). The review’s authors documented a reassuring growth in research over three decades (1980–2013), but also observed that ‘considering the diversity of crises, contexts and health care needs where humanitarian actors intervene, the volume of evidence available remains globally too limited’.
And so, the justification for R2HC’s existence became clearer. Since 2013, we have funded over 90 research studies spanning community practices during the COVID-19 pandemic in occupied Palestine to the impact of a health insurance scheme on health service utilisation, expenditures and health status among Internally Displaced People (IDPs) in Georgia, among many others.
As we approach a decade since the formation of the R2HC, we observed a major shift in research activities, and could see many more individuals, research groups and organisations actively committed to humanitarian health research than in 2013. As such, we commissioned a second Humanitarian Health Evidence Review to see what’s changed, and where more research is needed.
Learning from the 2021 Humanitarian Health Evidence Review
The review’s findings are promising, but with plenty of caveats. 269 studies met the inclusion criteria over an eight-year period, with an annual publication rate three times higher than the first evidence review. The types of interventions studied are also far more diverse, potentially reflecting a better appreciation of the broad range of essential humanitarian health interventions. These are positive developments.
However, the review has also identified many issues. Half of the published studies didn’t provide enough information to conduct a quality assessment, and therefore were automatically graded as having a high risk of bias. If practitioners and policy makers read an academic paper but can’t find all of the necessary outcome data or can’t tell whether the study sample is representative of the affected population, it’s much more difficult to accurately interpret and subsequently change policies and practices. To repurpose an old saying, “If research is published and no one can interpret it, does it make a difference?”
Looking to the future is the question of gaps. A substantial volume of research has been published, but how well does this research align with the needs of people affected by humanitarian crises, and the challenges faced by those trying to meet those needs? Some data from the review demonstrates a clear disconnect between research outputs and the people and places affected by humanitarian crises; for example, 8% of included studies related to IDPs as compared to 22% related to refugees, despite a 2:1 ratio of IDPs to refugees worldwide.
With input from a small number of thematic experts, some important recommendations have been made, but this review alone doesn’t answer the critical question of gaps. Only alongside other pieces of the puzzle — notably inclusive needs assessments and detailed prioritisation processes — does the full picture become clearer. We have already supported some of this work in specific sectors, such as wash, sanitation and hygiene (WASH) with the WASH Gap Analysis, and are collaborating with partners to develop research priorities for several sub-sectors including for WASH, mental health and psychosocial support and non-communicable diseases.
Not just more research, but a value-driven humanitarian research agenda
It’s important that we consider some of the limitations of this review, and how these limitations can also help to inform better humanitarian research. We purposefully only included peer-reviewed intervention research to draw out trends over time, but we know that evidence for humanitarian response comes from many places, and rarely just from behind paywalled academic journals. We also know that the dominant humanitarian and academic sectors have historically overlooked local expertise and situated knowledge systems, skewing the relative value afforded to different types of knowledge and knowledge-holders.
This recognition demands that we pay closer attention to the types of evidence that positively influence humanitarian programmes, often by asking those at the forefront of humanitarian practice what matters most to them, as we did recently with WASH practitioners from 14 countries actively engaged in WASH coordination and response from occupied Palestine to Madagascar, Bangladesh to Colombia.
It also demands that we invest meaningfully in research partnerships that are driven by the needs and perspectives of people and communities affected by crises, that ensure their participation and ideally their ownership of research activities, and that engage seriously with local research and operational expertise. Gestures of scholarly solidarity between concerned researchers who are remote to a humanitarian crisis should not be dismissed, provided that their input does not overshadow local knowledge and corresponding methodological and experiential expertise. With this in mind, it has long since been a requisite of any research funded by the R2HC that a research consortium must include in-country collaborators, precisely to mitigate against the real risk of more “parachute” research by minority world “Global North” researchers, which has marked the history of humanitarian and global health research.
Elsewhere we have explored where and how evidence from research is used. A growth in research is generally a good thing, provided it is orientated towards impact, and sensitive to the many barriers to research uptake, which frequently include a lack of perceived relevance of evidence and a lack of effective knowledge translation.
Not just a value-driven humanitarian research agenda, but solidarity politics
Aside from these constraints, examples abound of instances in which access to timely and relevant evidence has helped healthcare practitioners and policy-makers to make choices and act in ways that ultimately lead to better health outcomes for people living in situations affected by humanitarian crises. The effectiveness of community-based approaches for the treatment for severe acute malnutrition and the promise of shorter, safer and simpler drug regimens for drug-resistant tuberculosis have huge implications.
That said, we know that evidence alone doesn’t equate to better humanitarian action; values, vested interests, competing motivations, and money affect the substance of humanitarian relationships, and more fundamentally who receives assistance, when and how, if at all.
What humanitarian health research alone can’t do is foster a shared genuine concern for the health and wellbeing of others, nor can it illuminate the root causes of suffering and inequality worldwide. Growing indifference and isolationism are characteristic of the protracted geopolitical moment, and people affected by humanitarian crises will undoubtedly continue to feel this most intensely. By persisting in the promotion and conduct of health research in humanitarian contexts, committed individuals and organisations are refusing to co-sign a state of political indifference, and instead seek to identify more equitable, ethical, and effective ways to safeguard health and wellbeing that do not overlook people affected by humanitarian crises.
Determining where evidence has grown, and where major gaps persist, is central to a more refined humanitarian health research agenda and ultimately improved humanitarian response. With this in mind, I encourage readers to read the latest Humanitarian Health Evidence Review — and the diversity of research captured within it — and engage collaboratively to address persistent gaps in our knowledge of what works, and what doesn’t.
The second Humanitarian Health Evidence Review (HHER2), reflects a collaboration between Elrha and the Johns Hopkins Center for Humanitarian Health, led by Shannon Doocy, Emily Lyles and Hannah Tappis.