Freitag, 13. März 2015

Study Tour to Geneva, Switzerland

In early March, I was blessed to have the opportunity of travelling to Geneva with our study programm for a field trip to several International Organizations, organized by my university MCI (Management Center Innsbruck). Afterwards we had to write a paper to reflect on the tour and its learning outcomes. Since many people, especially those working in related fields, might be interested in these important organizations (as i always was!), but the opportunity to visit them doesn't present itself to everyone, i thought it might be useful to publish this reflective essay on my blog and garnish it with a few photos that i took in Geneva.

Overall speaking, it was an enriching excursion that brought new insights into specific topics, stimulated discussions not only with the speakers but also amongst us participants (we were 12 students travelling there), and gave us a glimpse of how it is to work in this field. It makes sense why there are around 200 of those IGO's (International Governmental Organizations) or NGO's (Non-Governmental Organizations) in Geneva: even if many of them may fight for the same cause, they all have their different structures, ideas and agendas. Complex societal problems are being tackled in this city on a daily basis, and these call for diverse, yet inclusive approaches and solutions. As the close proximity of these organizations (not only „in spirit“ but also geographically speaking) can produce fruitful „meetings of the minds“ and enhance dialogue, consensus & cooperation between the organizations, I suppose it makes sense to have them all in one place. And Geneva in Switzerland, in the heart of Europe, close to the French and Italian borders, easily accessible by train or plane, seems to be a perfect homebase. The train was also how I entered the country (for the first time ever!), traversing it from East to West, a great way to get a glimpse of the Swiss countryside!

I’m going to recap the content of the various presentations we’ve listened to, or at least the main take-home messages. On a second thought, I’ll add my personal impression of each organization, as well as the main learning outcomes from each presentation. Where possible I will try to dig a little deeper and add some of my own thoughts to the topic. I’m going to do this for each organisation, in „chronological order of appearance“:

First off on Monday morning was UNAIDS, the joint UN programme combating HIV & AIDS with 11 UN-related „co-sponsors“, although – as External Relations Officer Diana Rubin was quick to point out – this doesn’t mean that UNAIDS is sponsored by those organizations but rather that UNAIDS generates about 2/3 of the budget from national government donations (something Ms. Rubin is all too familiar with, working in the Resource Mobilization Division herself) and that the co-sponsors then add their own share (the WHO & UNICEF being the biggest contributors) and „comparative advantage“ to the organization’s profile. For example: as injecting drug users are one of the population groups most vulnerable to HIV, the UNODC (United Nations Office of Drugs & Crime), being one of the co-sponsors, may provide valuable know-how and data in this field.

Diana emphasized how important it is for HIV carriers to „know their status“ and how UNAIDS will be able to provide the nowadays affordable ARV (antiretroviral) treatment for around 15 million people by April 2015. She also mentioned Russia and Ukraine as being two regions of concern in terms of new HIV infections, mainly due to the criminalization of drug addicts and homosexuals in these countries, which drives them underground and makes them difficult to grasp for UNAIDS and their cooperating NGO’s. Diana pointed out the 4 pillars of UNAIDS work (Prevention, Treatment, Social Transformation and Closing the Resource Gap of about 5 billion US$), which are carried out in cooperation with national health authorities and local NGO’s, and the importance of civil society –especially the HIV-positive – being represented on the board of her organization. She pointed out – not without pride – that MDG 6 („halving HIV infections and reversing the trend“) is one of the few millennium development goals that has actually been achieved in the past 15 years, and that 2015 – if the trend is to be continued – could be „the beginning of the end of AIDS“.

Thus, for the next 15 years the organization has come up with the so-called „90-90-90 Target“ (90 % of people shall know their HIV status, of which 90 % will receive sustained ARV treatment, of which 90 % will have durable viral suppression) and hopes to reduce the number of new infections from currently 2.5 millions to 0.2 millions in 2030. The main take-home message was that even though many countries still suffer from the economic crisis, the resource gap needs to be closed because if current efforts are only maintained, the epidemic will skyrocket again by 2030. By „fast-tracking“ the response, however, we could more or less eradicate AIDS or at least its status as a global disease.

The glassy UNAIDS building and its translucent foyer was a sight in itself - the flatmate of my host in Geneva jokingly remarked that they put this shiny new building right across the road from the old WHO building to remind them what a poor job they have done at combating AIDS). Diana Rubin certainly did a great job at drawing everyone in on the topic, and listening to this young Austrian female who has carved herself a career in an international organization like UNAIDS was certainly inspiring for many of us, especially for my female colleagues. I also learned several new things about HIV and AIDS – the biggest eye-opener being that an HIV-positive mother could give birth to an HIV-negative (in other words: healthy) child through viral suppression and certain safety standards during delivery. It had never occured to me that vertical transmission of the disease (from mother to child) was avoidable, and that antiretroviral therapy has become so „affordable“, so I see the chances to beat AIDS in a different light now, although I still deem it a monumental effort. „Knowing one’s status“ will indeed be key to prevent future spreading of the disease, because it all starts with awareness of having it in the first place. Social transformation will be just as important, because underestimating the threat of the disease (and stigmatizing those who have it) are still major problems even in presumably well-educated societies, let alone in homophobic societies such as Russia. Regarding the aforementioned drug users there, changing punitive laws into assisting laws and employing „harm reduction“ such as in countries like Switzerland or Canada (i recently saw a documentary that portrayed Vancouver’s approach to the problem) presents itself as an almost Herculean task... however, that only underlines the importance of a supreme governing body such as UNAIDS to perform advocacy on the political level – „high-level bla-bla“, as Diana ironically called it. My main concern with UNAIDS is the accuracy of their numbers and thus of their calculations and projections, because – as Diana herself has pointed out – the organization has to rely on the data of her many partners in the field, which in some cases & countries may not be all that accurate.

On we went to the World Health Organization (WHO) on Monday afternoon, where we listened to 3 different presentations: Communications Officer Joel Schaeffer from Canada first introduced us to the profile of the WHO as the global public health authority -  its core structure (HQ in Geneva, 6 regional offices and 151 country offices), staff allocation (50% work in the country offices, the other 50% divided roughly half-half between HQ and regional offices), function (provide leadership, setting norms & standards, using evidence & research) and funding (75% from voluntary contributions, 25% mandatory contributions from UN Member States). The most striking figure for me were those 75% voluntary contributions, of which – according to Mr. Schaeffer – only 1% comes from Member States, meaning that the WHO’s money is partly (or dare i say: mostly?) private, something which wasn’t really apparent from our fact sheets and I had rather assumed to be the opposite!

As Joel pointed out (and i think all of us will agree) „fighting all diseases, all the time“ is a near-impossible task. Therefore, I think it makes sense for the WHO to confine itself to recommendations, guidelines & standards, old-fashioned as it may seem in an age of digital revolution. Let’s face it: despite (or rather: because of) all the information that is at our fingertips these days, what facts can we really trust? We’re literally drowned in it and – as time is a limited resource – it has become almost impossible to stay on top of it all - what is the truth, what are the cold hard facts; and what are just rumours or other people’s opinions? The current trend of parents refusing to have their kids vaccinated is sad proof of that. Therefore I have always respected  the WHO’s evidence-based approach and acknowledged them as the global authority on public health because as a physiotherapist, I’ve seen first-hand how little people know about health, or their own bodies to begin with (not that I blame them; education about it is poor, a dilemma that already starts in school), and therefore i understand the necessity of a supreme authority on the topic. Joel Schaeffer‘s background in communication made for a very clear and concise presentation that provided just the right amount of numbers and set the stage for the other two presenters. Dina Pfeier, Medical Officer in Health Security, talked about Epidemic Management in case of the Ebola outbreak in Africa. The „triage“ system and organization of a field clinic had already been covered in our lectures at MCI, but again, i learned a few new things (that the disease is rarely aquired through air, and that ceremonial burial practises in those countries include splashing attendants with water previously used to wash the dead bodies - a sure way to literally "disperse" the Ebola virus). Dina also offered some interesting insights into the challenges of setting up a field lab and many other coordination aspects of epidemic management aside the clinical part: behavioral & social interventions, handling the media, logistics, psychosocial support, epidemiological evaluation & surveillance and ethical aspects. She also enabled us to visit the WHO’s big conference hall and the „SHOC Room“.

Communication Officer Leilia Dore then concluded the WHO visit with a talk on the Polio Eradication Initiative, which was passionate and, again, inspiring for many of us since Leilia was not only female, but also about the same age as many of us. We learned, surprisingly maybe, that Pakistan is the main country of concern and together with Afghanistan & Nigeria these are the three main countries left on the „Polio Map“. The WHO’s strategy basically consists of vaccionation campaigns (such as „National Immunization Days“, which were successfully employed in India, since Polio vaccinations are fairly easy to administer) and the active surveillance of AFP in populations (Acute Flaccid Paralysis, the most common sign of acute polio). Operating in insecure areas is part of the challenge in all those countries which is met through community engagement, operational adjustments and political advocacy. WHO hopes to win the „Polio endgame“ by detecting & interrupting the virus, strengthening routine immunization, improving containment & certification standards to prevent „leaking“ cases, and legacy planning.

What impressed me about the WHO (apart from the international flair in the canteen and general buzz & diversity created by so many people from all around the world working in that building) was the level of professionalism & enthusiasm of their speakers. I’m fully aware that all the people we’ve listened to have probably received extensive training to live up to the task (otherwise I don’t think they’d carry titles such as „Communications Officer“) but it left us (even those who were a little wary of the WHO and considered them to be a bloated, bureaucratic apparatus) with the impression that this is an organization full of people that are not only skilled, but really do care. Some may still ask the question why the WHO needs to train and employ people just to project a certain image instead of using their resources for field work, but as I said before, I think it is important to have that global authority on public health, and with that kind of authority comes the need for an external communication policy and good outward representation.

On Day 2 we visited the Global Fund to fight AIDS, Tuberculosis & Malaria and were met by Beatrice Bernescut, who despite her French-sounding name turned out to be American, a very entertaining one in fact. True to the „Business as unusual“ ethic of the Global Fund she started her presentation with a highly engaging simulation, where each of us would be assigned a role and represent a certain constituency in a fictional country called N’kumbe that had very real problems (AIDS, Malaria, TB) and which perfectly illustrated the difficulty of reaching consensus, something of utmost importance in an organization like the Global Fund, which – similar to the World Bank – draws huge financial resources (the WHO’s Joel Schaeffer had even gone as far as calling them a „money-making machine“ the day before) yet doesn’t operate in the field itself, instead relies on domestic partners as „principal recipients“ of their money, who are then responsible for implementation. This is done with 3 main ideas in mind:

1.  Country Ownership, i.e. relying on local expertise & partners since every country usually knows best what works for them. Imposing one’s own ideas of what needs to be done in another country has often failed (and proven to be unsustainful in the long run) in the past.
2.    Performance-based Funding, i.e. the allocation of funds for a certain project depends on a valid proposal (called a „Concept Note“ at the Global Fund) and whether the money keeps on flowing depends on the project’s success by meeting certain evaluative criteria.
3.   Partnership, i.e. everybody involved in the fight of a disease should be involved in the decision-making as well. This usually includes civil society, especially the ones affected by a disease. These are included on the Global Fund’s Board with 3 out of 10 seats, a similar approach as the one by UNAIDS introduced to us on Day 1.

Even though some of us didn’t seem too impressed by the Global Fund for being a financial organization first and foremost, I must say I really like their way of thinking and the 3 principles above make a whole lot of sense to me. That being said, having one party who pays the money and another party who does the work, will set you up for all kinds of  problems (any employer/employee relationship is living proof), plus there’s the additional question mark that those who are major contributors to the Fund (pharmaceutical organizations, for example) may have their own interests in large-scale aid projects being implemented in a country – entering a market to sell lots of pharmaceutical drugs, for example. Another thing I originally didn’t like about the Global Fund is that they concentrate on 3 diseases only. If they really have so much money on their hands, couldn’t they invest it in other threatening diseases as well? However, Beatrice gave convincing arguments for all 3 (the huge financial burden from AIDS, as it has morphed from a death verdict into a chronic disease; the „potential wildfire“ of MDR-TB, a mutation of of the classic tuberculosis bacteria that requires 4x longer and 20x more expensive treatment; and Malaria resistance pockets around the world), emphasizing that these 3 diseases are „preventable, nobody should die from them, and there are low-cost, effective interventions for them“ (although you might argue that the fact that many of those 450 million insecticide-treated Malaria nets the Global Fund was responsible for were put to use as fishing nets by the local population can hardly be called an effective intervention). Focusing on only 3 diseases helps them effectively  channel their efforts (better to have great results in a few areas than mediocre results in many) but Beatrice didn’t rule out that the Global Fund may also tackle other diseases in the future, should the necessity and opportunity arise. She was also joined by an Asian fund portfolio manager (with a background in linguistics, interestingly) who briefly described what her typical working day looks like and what tasks a portfolio manager is involved with.

the view from the office of the Global Fund, revealed familiar territory: another IKEA warehouse

In the afternoon we visited two large NGO’s, the International Committee of the Red Cross (ICRC) and Médicines Sans Frontières (MSF) a.k.a. „ Doctors without Borders“. Even though these two organizations operate in the same field and have overlapping agendas, the presentations we received and the impression they left us with couldn’t have been more different from each other. Cédric Clerc, recently appointed Health Delegate of the Health Unit, first introduced us to the guiding principles of the Red Cross (humanity, neutrality, impartiality and independence) and current challenges the organization is facing: the increase in urbanization and difficulty to access people who seek help; demographic changes (contrary to most countries in the developed world, the developing countries are characterized by a young population – in Gaza for example, where Mr. Clerc had previously worked, 50% are under 18!); the multiplication of armed groups in conflict (where in the past there would be 2 conflicting parties, the situation is usually much more complex nowadays); the effects of the financial crisis and the presence of many humanitarian actors who compete for the same (diminishing) funds; and finally, the difficulty to find human resource for their work in the field, especially as health workers are increasingly targets of violent attacks, which led to the launch of the „Health in Danger“ campaign (later introduced to us by Bruce Eshaya Chauvin, Medical Advisor of the project).

Cédric explained that the rate of soldiers vs. civilians in need of help today is at 10 vs. 90 %, which is a complete reversal of the past, and a testament to two things: the Red Cross‘ expanded role in helping with natural disasters, but also to the changing ways wars are being fought today. Whereas in the late 19th century, when the ICRC was founded, conflicting parties would usually clash on a battlefield, the battlefield today could be anywhere: civilians killed by unmanned drones & missiles in Iraq, ethnic genocide among minorities in villages in Central Africa and the Middle East, people perishing in the collapsing World Trade Centers, 200 innocent school kids trapped by a gunman on a killing spree on an idyllic Norwegian island, and whoever is unholy and unlucky enough to get abducted or killed next by the Islamic State Militant Group... these are but a few examples of the volatile and unpredictable nature of conflicts today.

The informal „Pizza Dinner“ at the MSF headquarters that night was quite different from all other presentations on this study tour. Maude Montani, Research and Publications Officer at MSF, received us in a dark & deserted office and guided us downstairs to a meeting room, where she proceeded with a presentation about MSF while we were munching on pizzas... which i found a little odd, to be honest. However, these little oddities are exactly what makes MSF a very charming organisation: the tour through their offices revealed a smaller, obviously much less bureaucratic organization, where one could still feel the idealistic spirit of the founders. After all, as we had already learned before the trip, MSF was founded by doctors & journalists, some of whom had previously worked for the Red Cross and were frustrated with their bureaucracy and inability to speak out about the grievances in the world. And while MSF, just as the ICRC, acts as an independent, impartial and neutral organization, it places emphasis on their added concept of „temoignage“, i.e. being a bearing witness in conflict, and speaking out about it, in other words: letting the world know what’s happening.

As mentioned before, the Red Cross has shifted a lot of its work towards natural disasters, which includes plenty of infrastructural work, and consequently Doctors without Borders focus more on clinical management of diseases & epidemics (such as the current Ebola outbreak, where they have actually lost quite a few workers). I suppose this specialization makes sense, even though it might be difficult for people on the outside to decide which organization they should donate money to. I would probably have chosen MSF in the past, because I already knew a few doctors who had worked for them on standby, and i think I would choose them even more so after this trip, because of their hands-on, make-a-difference approach and the humble charm of their headquarters.

Even though deserted, the offices of "Médecins sans Frontières" invoked the spirit of young idealists at work

On Day 3, we visited our last organization, the United Nations High Commissioner of Refugees (UNHCR) where we first watched a video about the history & tasks of the organization, and then listened to a lecture by Legal Officer Alexander Beck, Protection Policy and Legal Advice, about the division of international protection and the UNHCR challenges in the area of mixed migration. Although us and Mr. Beck got off to a somewhat bad start, his presentation ultimately was quite satisfying. As a lawyer, he was very keen on distinct terminology, and when he showed us a picture of African refugees crossing the Mediterranean on a wooden boat, and asked us whether they’re refugees or migrants, I gave the only logical and correct answer: You simply cannot know. Each case comes down to the individual, and it is important to try to avoid general assumptions, as comfortable as they may seem. Alexander described the typical path of a migrant/asylum seeker, and his/her dependance on human traffickers, border guards, police authorities and finally immigration authorities. He made a strong case for legal travel documents for asylum seekers so they can travel around (which they will try to do anyway) in an unobstructed way and go directly to the country in which they want to apply for a visa; often asylum seekers have a certain destination in mind (due to family ties or other preferences), but they don’t always get there, since they will be presented to the asylum authoritites of whichever country they happened to be apprehended in. Therefore, they may have a weaker case to present (and once an asylum request is denied, that denial is valid for the entire EU in order to prevent multiple applications).

With a large share of lawyers working at UNHCR it became pretty clear (or rather, Mr. Beck made sure we understood) that public health specialists are not necessarily high in demand at the organization. He compared the organization to a government’s foreign office (with their HQ in Geneva and lots of „embassies“ all around the world) and listed political advocacy and supervision as the most important tasks; establishing a permanent contact with state authorities. The interesting thing is that these local UNHCR offices may look very different, depending on the country. Whereas a country like Austria only has a small office in Vienna, with 2-3 lawyers doing mainly supervisory work, a country like Lebanon and Jordan, who currently receive a lot of asylum-seekers (due to the conflict in Syria) but are ill-equipped for proper asylum procedures, forces UNHCR to step up and handle the „field work“ themselves. However large their extent of interventions may be, Refugee Law and Human Rights Law always form the legal basis for action, which explains the high share of lawyers in the organization. Even though Mr. Beck didn’t go into specific cases, his descriptions were vivid, and having met both asylum seekers and refugees in my previous job i now have a clearer understanding of what challenges and difficulties they might have been facing on their voyage.

The visit at UNHCR also strongly reverberated after our return: already on the train home, I read an article about mixed migration and a portrait of two families with a migration background. The next day, I heard UNHCR employee William Spindler speak out on public radio and suggest that „commercial ships should be compensated for any extra costs incurred by saving migrants‘ lives, adrift in the Mediterranean Sea“, because the replacement of Italy’s MARE NOSTRUM programme through the current TRITON operation has literally put a lot more refugee boats in dire straits. And just yesterday I got into an online argument with a distant facebook „friend“ (someone who I’ve only met once personally) about immigration & asylum policy in our country, which led to me having to „unfriend“ that person – something I don’t like to do, because I think it’s important to discuss with people, even if you don’t share their beliefs; isolating them will only make things worse. Before I did that, I recommended him to travel, because travelling can be an easy and meaningful way to broaden one’s horizon. Reflecting on that, I think that this trip to Geneva (and the visits to these organizations) certainly helped us all to broaden our horizons and grow personally & professionally!

the impressive lobby at UNHCR

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