Dr. Richard Brennan, WHO Emergency Operations: The “Delicate Dance” with the Taliban

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Andrew Schwartz: You're listening to the Covid-19 Update a podcast from the CSIS Global Health Policy Center, focused on the science and policy implications of the outbreak. I'm Andrew Schwartz of the Center for Strategic and International Studies, and I'm joined by my colleague, Steve Morrison, to discuss the latest on Covid-19.

Steve Morrison: We're delighted today to be joined by Dr. Rick Brennan. Rick is the Regional Emergency Director for WHO Regional Office for the Eastern Mediterranean, based in Cairo, Egypt. Previously, he had spent seven years at WHO headquarters as Director of Emergency Operations, Director of Ebola Coordination and Response, and Director of Emergency Risk Management and Humanitarian Response. We're going to focus overwhelmingly today on the catastrophe unfolding in Afghanistan. We'll talk about Covid and the Covid response, but also a full range of other issues, especially pertaining to the risk of collapse of the Sehatmandi health project that sustains 2,300 facilities inside Afghanistan. Thank you, Rick, so much for joining us today. Andrew Schwartz cannot be with us today and sends his regrets.

We’ve had the great fortune to enlist Len Rubenstein, a close friend and collaborator and Professor of the Practice at the Johns Hopkins Bloomberg School of Public Health and Director of the Program on Human Rights, Health, and Conflict. He's the author of the recently published volume Perilous Medicine: The Struggle to Protect Health Care from the Violence of War . He founded and chairs the Safeguarding Health in Conflict coalition. He has, for a very long time, as we'll hear in this conversation today, tracked the health sector within Afghanistan and the many complexities that have entered the history of that sector going back in recent decades. Recently, Len and I published a CSIS commentary, which you can easily find. The title is “Pulling Afghanistan back from the Precipice—without Capitulation”. This conversation today with Dr. Rick Brennan grows out of that earlier work.

Rick, let's get started by asking you to talk a bit about your own personal background, your own personal story. What was the path that led you from medical training in Sydney, Australia to the CDC in Atlanta, Georgia, to working for the International Rescue Committee in New York for 10 years as Director of Operations, to two and a half years in Liberia working with JSI, and then on to Geneva as Director of Emergency Operations, and now Cairo? Tell us a little bit about your own personal story. It's quite interesting. It's quite unusual.

Dr. Rick Brennan: Yeah. Thanks. Thanks very much. Well, I trained as an emergency physician in Australia. That was back in the 1980s, and in those days, emergency medicine was a brand-new specialty in Australia. And then I came to the U.S. and did a fellowship, a research and clinical fellowship, went back to Australia and was Director of Residency Training and Director of Research at Australia’s largest trauma center. And during a period of about 18 months, I did three volunteer missions to go to Bosnia during the war in the early nineties.

I got very interested in humanitarian action, and a number of my colleagues there that I met had their public health degrees. I was an emergency physician—I had no clue about public health. So I resigned my job. I thought, well, I'd like to pursue a career in this area. I resigned my job and, not knowing anything about public health, I came back to the U.S. and was accepted for my MPH at Johns Hopkins, where I was exposed to some great people like Professor Paul Spiegel, who was a classmate, but also connected with colleagues at the CDC at the time, and I became much more interested in a career in national health. Long story short, I got a temporary assignment with the CDC during the Atlanta Olympics. They kept me on, and actually I ended up being seconded to a unit in Hawaii, of all places, run by the very well-known Skip Burkle, the Center of Excellence for Disaster Management and Humanitarian Assistance. I was the CDC secondee there for two years, working closely with the U.S. military on humanitarian action, civil military relations, CBRN issues and so on.

And then very fortuitously, I was subsequently asked to do a review of the health programs of the International Rescue Committee and design a health program for them while I was still working with the CDC. I was so impressed by the organization, I applied to be the Director of their newly established health unit and stayed there for 10 years, perhaps the best professional experience of my life. Wonderful decade in New York, running a team that provided technical and operational support to humanitarian programs in 25 countries.

From there, I went to Liberia, as you mentioned, with JSI Research & Training. It was a great time to be in Liberia—it was just emerging from years of civil war. They had a new rock star president, Ellen Johnson Sirleaf, who subsequently won the Nobel Peace Prize. The health minister at the time was regarded as perhaps being the best in Africa. We ran this big post-conflict health system reconstruction project funded by USAID, and I was the head of that project. It was a wonderful experience. Then the idea of that program was to hand over everything to the Liberian staff, which we did after two and a half years.

Then I got picked up to go and run the Humanitarian Department at WHO, in Geneva, and on the back of a couple years later, actually four years later, after the Ebola response, WHO decided to integrate its Disease Outbreak Health Security Team with its Humanitarian Team. And I was the Director of Emergency Operations there within that new program of Health Emergencies, and I stayed in that role as Director of Emergency Operations for about another two and a half years before coming here to Cairo to be the Regional Emergency Director. So, I'm sorry, that's a bit of a long story—

Dr. Morrison: It's an amazing pathway. Len, you've been studying emergency medicine and conflict and medicine. It sounds like Rick's pathway has sort of coursed through all of the major zones of the last 20 years.

Leonard Rubenstein: Yeah, in fact I was in Liberia just as Rick was beginning to work on that program. And, of course, at the time it was enormous amount of optimism with a charismatic leader and health minister, Walter Winagali. And then I worked with Rick and WHO on the program to track incidents of violence against healthcare. So our paths have crossed many times.

Dr. Morrison So Rick, tell us, just give our listeners a better idea about what exactly are you empowered to do? What's the mission there in Cairo for the Eastern Mediterranean Regional Office? You've got a big job, but tell us a little bit about how you operate and what do you have at your disposal in terms of tools to address these crises?

Dr. Brennan: We actually cover 22 countries. So from Morocco in Northwest Africa, across the Middle East, as far as Afghanistan and Pakistan. We also cover Djibouti and Somalia. So, of those 22 countries, 10 of them have large scale humanitarian crises. We are home to 9 percent of the world's population but 43 percent of the world's population needing humanitarian assistance right now. We have over a 100 million people, 101.9 million people, right now, needing humanitarian assistance. We have a source of two thirds of the world's refugees, just these 22 countries. We are prone to multiple emergencies, not only the conflicts in places like Syria or in Yemen and Afghanistan and Somali and Libya and so on, but also, of course, disease outbreaks in addition to Covid. We've had 21 significant disease outbreaks in the last year that we've responded to. Natural disasters, of course, such as recurrent floods and droughts on the back of and exacerbated by climate change, earthquakes, and quite a few technological disasters as well. So, your listeners will be familiar with the port explosion in Beirut Port last year, where you had trauma supplies on the ground within 25 hours of that, and multiple chemical attacks in the early days of the of the Syrian conflict. So it's a very complex mixing.

Dr. Morrison: Rick, how has COVID figured in your work, in the course of the pandemic?

Dr. Brennan: I would say for the first year, in spite of the fact that we have five of the seven largest humanitarian crises in the world in our region, we were so overwhelmed with the Covid response and the demands to scale-up, which affected all countries. I would say I dedicated probably 70 percent of my time just to get the strategies going, and we worked through all phases of the emergency management cycle—prevention, preparedness, detection, response, and recovery. I've got disease experts, I've got preparedness experts, we've got information management experts detecting emergencies, and then strengthening surveillance systems, monitoring the impact, as well as the response side. So, we have a comprehensive approach and we've worked on all aspects. WHO early in the response developed a strategic preparedness and response plan that had nine initial response pillars, from surveillance to case management, to points of entry and laboratories, and infection prevention and control, and so on. We rapidly tried to support the scale-up of the response across all those pillars in all the countries, clearly with a particular focus on the vulnerable countries, the lower-middle-income and low-income countries, but also guided by the epidemiology, which was bouncing around the region a lot in those first twelve months.

Dr. Morrison: Thank you. We want to center much of our discussion in this conversation around Afghanistan, the crisis there, what's unfolding, and your active role here. Let's start by getting your reflections on your prior experiences in engaging with the Taliban and your experiences, your reflections, on how they look at the health sector. I know Len has some thoughts on this also. I would like him to jump in, perhaps right now, and offer some thoughts about the way that people have looked at the Taliban, those who've watched its behavior over the years and treatment of the health sector. Len?

Mr. Rubenstein: The Taliban seem to have had a really complicated relationship with the health system. Described by Ashley Jackson, it is evolving from attacking healthcare to co-opting it—often allowing programs to operate, but demanding controls in hiring, payments for services, and other forms of coercive interference. Just recently, in the last couple of days, there was an AP story about a Taliban-appointed administrator of a health program, really kind of undermining some of the gender equality within a health post at a hospital and spending money on a mosque instead of drugs. I'm curious what your experience has been with the Taliban over recent years.

Dr. Brennan: Yeah, what I would add to the description that you mentioned is, I would say their first approach to the health sector, when they were in power in the late nineties and early part of the 2000s, was neglect.

My first visit to Afghanistan was in 2000 when the Taliban was in power and there was virtually zero support from the central authorities for the health sector, and it was largely propped up by the NGOs. And then as you described, subsequently there were attacks on healthcare.

I think we're still working with what we’re calling a delicate dance with the Taliban today. They appointed a minister of health, who I think is very open and a good listener. He's a medical doctor, he's a urologist. I mean, the Taliban authorities now see themselves as the legitimate government within Afghanistan. Clearly, the international community hasn't accepted that. The international community previously had funneled an enormous amount of money through the health system and the Ministry of Health to support the delivery of essential health service, through the famous Sehatmandi project, which we'll come back to. Now, because the Taliban's in power, the major donors have frozen and paused their funding, and the Taliban is confused. They see themselves as the government, so why isn't the international community coming in and providing the development systems that they did before? What's happening to all these big projects? So, we are trying to engage them, coordinate with them, collaborate with them, but we're not giving them decision-making authority over any of our programming activities right now.

So, we are doing progressive advocacy, on clear access of women and girls to health facilities, and continuing the training and support of female health workers. We also do surveys a on a weekly basis to review the functionality of health facilities. Of concern—well this is good news and bad news—96 percent of health facilities are currently functioning to some level, only 17 percent are functioning fully. 95 percent of female health workers are turning up to their posts in these facilities right now. And that's been a consistent trend that we've seen, a consistent figure, but around 77 percent of the health facilities have got stock-outs of essential medicines. So, they're not working well. There are anecdotal stories of women and girls being reluctant to come to health facilities.

So, we're still in this negotiation with them, trying to ensure that there is continuity of health services, and that we don't overstep the mark with respect to the donors and the United Nations, which officially are saying we cannot build capacity or invest in any institution associated with the Taliban administration. And at the same time, we have to be advocating on these important gender issues and the access that women and girls have to health services and education, including training as healthcare workers.

Mr. Rubenstein: We'll come back in a moment to the healthcare system. I just want to follow up about the health minister. You said they've appointed one and he seems committed to the health system. One of the concerns in recent years has been that the local, provincial health appointee— in those days, shadow provincial ministers— and now, whatever role they're called, having a lot of authority. Do you see that health minister as having control of these people, even if not absolute control, control enough to make sure there's not gender segregation and that they will follow medical protocols that the minister of health agrees with?

Dr. Brennan: Len, I think it's a bit early to say right now. We've had some problems out in the east, certainly, with one of the Taliban administration figures suspending mobile clinics, for example, in one instance. The short answer is no, I don’t think the Minister of Health at this stage has been able to assert authority at the provincial level. And I don't think that that's probably going to be particularly likely in the context of Afghanistan.

What we are trying to do is decentralize our presence to make sure that we have strong field presence. We already have staff in all 34 provinces through our polio program, but it is going to be a lot of dialogue on a case-by-case basis at the provincial level, as you indicated. And we're in this for the long haul. There’s not going to be simple decisions. You know Afghanistan—decisions made centrally more often are not played out at the provincial level. So we've got to be fully engaged in the discussions at provincial, as well as central levels.

Dr. Morrison: I'd like to come back in a moment to this question around how you achieve some sustainable financing for the health system that navigates this problem that you face, where you can't be capacitating the Taliban government, but you can't allow the health system to collapse. We’ll hold on that for a moment.

You and your team were very successful, it seems to me, acting in partnership with other governments and other UN agencies to do several things very quickly as the Taliban came into power in mid-August. That included getting emergency medical kits into the provincial capitals, getting trauma kits for those wounded, opening air links into the provincial capitals after Kabul airport had closed and there had been destruction, and it was really a very fraught period. You were able to win an agreement a short while back around the third week of October, to resume immunization programs for Covid-19, for measles, for polio. To win agreement from the Taliban, to take that very, very important step—tell us a little bit about how that became possible. How were you able to move rapidly across those different fronts, which seemed vitally important at avoiding the worst outcomes and demonstrating that you could move forward in the midst of a very chaotic and a very dangerous and uncertain context?

Dr. Brennan: Let me say those three points, how we get medical supplies, how do we ensure the continuity of health services with support from the Taliban, and how do we get their agreement for the vaccinations.

So, the second half of August—chaos. Our top priority, as you would understand, was the safety and security of our staff. We, like all UN agencies and international agencies, went down to just essential staff. We evacuated most of our international staff and had only six in the country.

At the time, the big international evacuation from Kabul airport was in motion, and we could see that health needs were escalating. We had a lot of medical supplies in our logistics hub in Dubai that we couldn't get into the country. We tried to take advantage of all these military aircraft coming into Kabul. We're going to give back to people. In fact, the white people, we would try to convince governments to allow us to put a lot of medical supplies on those flights. I won't get into the details, but it just didn't work. We couldn't get any medicines onto those flights going into Kabul.

So, we started knocking on a lot of other doors, and we finally got the Pakistani government to agree to put a flight from Pakistan International Airways at our disposal. We couldn't fly it into Kabul because of the huge evacuation operation. So we flew it into the Mazar-i-Sharif in the north of the country. But by that stage there’d already made the attack at the airport, and insurance costs for aircraft skyrocketed. That one flight cost us well over $600,000 just to get some medical supplies in, but it was a start.

Then we linked up with the World Food Program and the Humanitarian Service, as well as the Qatari government and we just pasted it together. Now we've had around 12 or 13 airlifts bringing in medical supplies. We have distributed to all 34 provinces—that really took a lot of piecing together.

Secondly, about four weeks ago, the Director General of WHO, my boss the Regional Director, and myself joined the delegation that went to Kabul. We were the first senior international leadership, the Director General meeting the Prime Minister of the Taliban. And then in a couple of days, the new Minister of Health was appointed and a couple of us met with him as well.

The Prime Minister and the Minister of Health made it very clear: we're not going to let you do anything with vaccinations or anything else until you get the Sehatmandi Health Project going again. And then coming back, for those listeners who aren't familiar, Sehatmandi is the backbone of the national health system. 2,300 health facilities funded previously through the Ministry of Health with performance-based contracting with NGOs, and all of a sudden, the big donors suspended their funding.

Dr. Morrison: This is the U.S., EU, and World Bank.

Dr. Brennan: Precisely. All of a sudden, the NGO’s said, “We're done, we’re not going to support these health facilities beyond [I think it was] the 11th of September,” so we had to find a bridging way to sustain the operations of those facilities. A couple of other donors and the UN agencies, we came together, and we've got a quick fix. So, for the month of October, the Global Fund supported UNDP to fund the NGOs to continue to support those health facilities

Dr. Morrison: We had Peter Sands here about two weeks ago, talking about that decision.

Dr. Brennan: Yeah, and it was absolutely vital. Great decision. Then OCHA, through what's called the Central Emergency Response Fund said, we'll put $45 million forward for the humanitarian agencies to take because the Global Fund can only fund for a month. So, through the survey, this special fund, we’ve given the money to WHO in unison, and we have essentially split the country in half and we're taking 17 provinces. UNICEF is taking 17 provinces and we're going to keep the facilities running for the next three months. Then World Bank, because of their internal processes, still cannot support the government. So they're looking at a couple of different financing mechanisms that they have. They will probably release funds to UNICEF and or WHO, who either way will work together to continue funding for another five or six months until we can have longer term support from the donors.

So, we're piecing this together in three or four phases. We hope that the Bank will step up around February and continue the support for the health facilities. And then by the middle of next year, we're again hopeful and in negotiation with them on a regular basis, and USAID, about longer-term funding. It won't be like it used to be, with the money channeled through the Ministry of Health or through any Taliban administration-run institution. It'll probably be something more akin to what we do in Yemen, where the World Bank fund WHO and UNICEF to support a large proportion of the health facilities across the country. And we'll probably use the Yemen model in Afghanistan.

Dr. Morrison: One of the big questions here is, as you try to create this sustainable structure that can extend beyond February and stabilize the Sehatmandi system, these 2,300 hospitals and clinics, getting concurrence from the Taliban is a critical challenge. Len, you had some thoughts on this probing question here. Why don't you join?

Mr. Rubenstein: I’d like to ask Rick—this is really threading a needle—as you said: the Taliban want to be the government. They appointed a health minister. They want control but the donors won’t allow them control. Do you see a way of threading that needle, that the Taliban would cooperate in a system where they may have some voice but not control, and how do you see that voice expressing itself?

Dr. Brennan: To date, they're accepting of what we're trying to do, to the extent that once we agreed to continue supporting Sehatmandi, a big priority, and believe me, there are plenty of priorities that we haven't even touched on in Afghanistan and health sector right now.

Based on that, they agreed to renew the vaccinations that you were talking about. The house-to-house campaign for Polio, which is a huge breakthrough, because we've only had one polio case in Afghanistan. It’s one of only two countries with wild polio virus so that's a big breakthrough.

They're going to let us do measles vaccination campaign and scale up the Covid vaccinations as you mentioned earlier. We're going to have to wait and see how things evolve.

I think we have taken steps to establish a respectful relationship with the Taliban, a consultative relationship. We want to coordinate and consult with Taliban officials. But right now, we can't give them decision-making authority on any of the measures that we're taking within the health sector, because the donors won’t like that. But we've got to coordinate, collaborate, listen, and make sure that their voice is heard. We're not going to shut them out. That would be the worst thing we can do. They're the only show in town in terms of governing authorities. So, we have to coordinate with them, but not be coordinated by or dictated to at this stage.

Dr. Morrison: I just want to say a few things, Rick, to what you, the story that you've just told us. First of all, congratulations to you, kudos to you for moving this fast and across these multiple fronts, but also kudos to Peter Sands, a global fund and Martin Griffiths, director of OCHA, and Henrietta Fore at UNICEF, and Dr. Tedros. These folks came to the table in earnest, they were in Kabul, and they have delivered in a way that has avoided a precipitous collapse. It may not last, and we'll get to the question of is time running out and, and how urgent to get to a stable long-term thing. But I do think that all of you and these other leaders that I've mentioned deserve a lot of credit for operating under extraordinarily adverse conditions and being able to pull this off. On the Covid-19 front, as I understand, you had a certain urgency. Also, you had about 1.6 million unused doses that were heading towards expiration in early to mid-November. You've got promise of additional doses coming in through COVAX, I believe, but you needed to get that rolling. I mean, the percentages are far below 5 percent, I believe. And so, the urgency of getting that program back up and running—it pretty much collapsed around August 15th, right? They had ramped up to, I don't know what it was 30 or 40,000 a day, and then it dropped dramatically.

Dr. Brennan: You’re right, and in fact, all aspects of the Covid response declined after August 15th. We saw fall offs in the surveillance, in the testing, and the operations of the COVID hospitals. There was 38 of them. At one stage there was only eight of them functioning. And as you rightly said, we were vaccinating thousands a day that fell off to some days only a few hundred.

The good news is that the health workers, and this is the remarkable thing, even though they haven’t been paid their salaries and so on, they're turning up and doing the job as best they can. So have we, and you're absolutely right in what you said about the expiration of the vaccines and others in the pipeline—so we have started scaling up the vaccinations.

Back four weeks ago, we estimated that to avoid the expiration of vaccines, we have to get up to over 40,000 vaccines per day. We're still not quite there on a consistent basis, but that's scaling up, and one of the problems we have with Covid right now. It's one of the many crises, one of the many challenges right now. The population isn't paying attention to the public health, the social measures, the personal protective measures. They're not foremost in the mind of the Afghans right now. So we've got a lot of work to do.

We've got this big drought, we've got over 500,000 people who are still displaced. We've got massive problems with food insecurity. We've got other ongoing outbreaks of measles and dengue, and now, frankly, diarrhea in five provinces. All the trauma, all these multiple trauma events. So we're working hard with partners to get our arms around all of that. And Covid-19 we've got to keep it on the radar screen, even though it was hard to do so, no surprise: the delta variant is circulating in Afghanistan. So we're really trying to redouble our efforts there as well.

Mr. Rubenstein: I want to second what Steve said, and congratulate you on all you've done so far in dealing with so many crises at the same time, including keeping health workers, working, keeping clinics going, and also walking this line between Taliban voice. Without Taliban control in the long-term, do you see the donors buying into the model of supporting the system in a Yemen type model or other kind of mechanism that would have outside control, but allow Taliban voice?

Dr. Brennan: I think we will go with Yemen model, probably in the middle of the year. In the Yemen model, the money comes directly with UNICEF and WHO. So, none of the money is channeled through the government. And again, we consult, but we don't take direction from the government, and we pay a lot of the government salaries. So, again, it's always a delicate dance in those kinds of settings.

As to whether we'll get back to a situation of where funding will be channeled through government structures, I think that's probably a long way in a way that's ultimately a political decision. And of course, the litmus test, I think for the international community is on how we engage with the Taliban on other rights issues: the rights of women and girls, of the rights of minority groups, you know, and so on. We need to see it’s clear that international governments and international donors are watching issues like that before they decide to engage more constructively and do get back any sense of institution building in the country.

Dr. Morrison: The issue of women and girls—I'd like you to say a bit more about that, you know you opened up by saying, “look, the workforce is in place and still able to function.” The polio vaccinators are predominantly women, and access to services by women and girls has not been shut down.

But then again, we have this outstanding issue of local Taliban control to separate male from female providers, separate services, and intervene in different ways. How do you monitor that? I mean, the health sector it seems to me is more favorable towards preserving the rights of women and girls, both in employment but also in access to service as against the education sector, which has been very problematic.

As you might imagine, media and higher education, there's struggles that are going on there. It seems to me that what was accomplished in this Sehatmandi system, and in the polio efforts, was accepted by the Taliban during the years of war and where they have shadow presence in these provinces. Tell us a bit more, is there the potential to preserve those gains in the Sehatmandi system and the polio program, so that there's not a serious regression in terms of women and girls?

Dr. Brennan: I certainly hope so. And again, decisions made essentially may sometimes not be born out or played out at provincial level. Another bit of good news as we renew the house-to-house campaigns for the polio vaccination, is the frontline female health workers are engaged in that campaign. So that's another important step. I get the sense that female health workers will still be able to continue to work.

I'm worried about the other end. I'm worried about exactly what you said. I'm worried about what's going to happen in the education system, and the pipeline of young potential female healthcare workers graduating from high school, and then going off to study to be doctors, nurses, midwives, and so on. That's where I worry that the pipeline might be shut off if we don't see girls access to education being equal to that of boys. That's been one of the success stories in the last two decades, is the training of healthcare workers, particularly female healthcare workers. We can’t have a rolling back.

Dr. Morrison: Say a bit about the security situation. We had the report today that ISIS K attacked a military hospital in Kabul. It has done that before, and a number of people were killed and injured at that attack. This comes on the back of the attack upon mosques during prayer. Kunduz, Khandahar, obviously the big attack at the airport, too. How does this impact what you're trying to do?

Dr. Brennan: That's another layer of complexity. I mean, it's a tough, tough operating environment right now in some ways. Well, in many ways, security is better than it was a few months ago. The Taliban has committed to protect healthcare workers and protect humanitarian workers. When I tell my family I'm going to Afghanistan, they reel back in horror. When we were traveling around Kabul, it was a Taliban security detail that was escorting us around. So, the big unknown, of course is exactly what you said, ISIS K, these terrorist attacks. We feel pretty safe and sound with the protection from the Taliban, as their administration needs the international community. So, they are trying to ensure that the operating environment is as conducive to us staying and expanding as possible.

Right now, the UN and international agencies haven't been a target for ISIS K. I mean, I guess there was clearly US military at the airport back in August. So, we're very vigilant, we're very vigilant at this stage. We know they have the capacity to attack us, but we're committed to staying and delivering. We are very vigilant.

As I mentioned, we've consolidated all the humanitarian agencies into one compound from the UN in Afghanistan. It’s a very fortified compound. But ISIS K is definitely the biggest risk right now.

Dr. Morrison: To the degree you can offer reflections on what this experience has taught you that's new and different, what would that be? What are the deep lessons up to now from what you've experienced in Afghanistan?

Dr. Brennan: I thank you for the kind remarks, I agree. I think it was great the way that the Global Fund stepped in together with UNDP, UNICEF and ourselves to fill that gap. I think that that having that flexibility was absolutely vital. I think we showed a lot of agility. And again, another example would be how we work together, the amperage to get medical supplies. I feel much more confident we can do this now and in future similar circumstances, as we've strengthened our partnerships with a number of our members sites. We've strengthened our partnerships, certainly with UNICEF.

Dr. Morrison: But you were very reliant on active cooperation from the Qataris and the Pakistanis in particular, right?

Dr. Brennan: Yeah, the Qataris have been tremendous. I have to say they received a lot of the evacuees. I'm in touch with the Ministry of Foreign Affairs sometimes on a daily basis trying to get supplies and trying to get people out. Trying to get aid workers in, getting them out. And, just bending over backwards for us. Again, it isn't easy for them either. We are, as Len said, threading that needle trying to maintain a constructive, engaged, consultative relationship with an administration that doesn't have the support from the United Nations or any of our donors. Trying to engage them while at the same time having clear red lines about what decision-making we can allow them to have.

I mean, it's uncomfortable, because in a sense they're perceiving us as “who the heck are you to come in and run our health system?”, and so we’re trying to be as diplomatic as possible, and as sensitive as possible to their perspective. I think the new Minister of Health has been quite constructive in the dialogue with him. That's been a learning experience and it'll continue to be, as well as engaging with the big donors about how you address the risks of wholesale collapse of the health system, and the advocacy that we've done on that. We’ve got the word out. I think the advocacy element of that and the way that we did the joint advocacy with UNICEF was important as well.

Dr. Morrison: Now you said earlier that EMRO in Europe and the emergency office that you run in Cairo—you've got five of the seven largest humanitarian emergencies on your plate. You've got to think about Lebanon, which is in a freefall. You've got the continued crisis in Yemen and Syria. And, you've got Afghanistan and other situations.

Do you think that what that suggests in terms of lessons learned, is that your shop in WHO, in both Geneva and at the regional levels, needs higher capacities—whether that's personnel, transport, finance, quick release, finance, contracting capacity, or whatever. I mean, it seems to me you're doing extraordinary work in extraordinarily difficult circumstances across quite a swath of complicated crises.

Dr. Brennan: No, you're absolutely right. Our structure and capacities, frankly, are not fit for purpose to take on all the responsibilities that are expected of us. We’re responding to a pandemic as well. So, we did what is called a functional review of our operations. It was completed just before the pandemic, and it demonstrated that we didn't have anywhere near the stopping capacity that’s required. Even now I've got about a hundred posts, and only 65 of them are filled in the field because of funding. But it’s not only funding gaps—this is not an attractive part of the world to work in or live in for many people. Just to give you a little anecdote—I, just a week and a half ago, got back after spending a week in Saudi Arabia to do a technical exchange over the Covid-19 response. And we learned a lot from the Saudis, and I think we were able to teach them a few things as well.

I got back, I'd been on the road so much over the previous few weeks for Syria and Afghanistan. I thought, “great, I've got a whole week where I didn't have to travel and I can catch up on a lot of stuff”.

I wake up on Monday morning to learn of this coup in Sudan. So, I get on the phone, I immediately call our emergency team lead there. She says, “thank God you’ve called the phone lines are down. I can't accept a call through my international phone, but I haven't even been able to speak to any of my staff anyway”.

So how we bridged together phone connections there over the next couple of days to make sure that our staff was safe and secure, and made sure that we could launch some sort of operational support was very, very tricky—but this is living in our region. But I did hear some good news today—I did hear that WHO headquarters was substantially increasing our funding because they realized that we are critically under resourced.

I think we are able to demonstrate impact. I can give you good figures where we've set international standards on humanitarian action in some of the toughest, toughest operating environments in the world. Yemen, Syria, Palestine, and on, and on, and on. But, unfortunately, there's a lot of demand on the humanitarian dollar these days. Two of the biggest problems we have right now are sustaining donor interests in Syria and in Yemen. What we're expected to do in those settings with very limited funding, and deteriorating funding, is difficult. But donors and the international community had enough. There are other crises in Ethiopia, elsewhere, and climate change battling for attention as well.

Dr. Morrison: Len, we're getting towards the end here—your closing thoughts.

Mr. Rubenstein: Well, I want to just congratulate your work on all you've done. As you've said, it's an incredibly tough job with multiple crises. It looks like if there can be preservation and the sustained healthcare in Afghanistan, you're on the right road. And I know it's not going to be easy because of this balancing act, but I really wish you well.

Dr. Morrison: Thank you, Rick. We close these podcasts by asking each of our guests what gives them hope and optimism. So, we're going to throw that question over to you.

Dr. Brennan: Having worked in humanitarian settings for over 30 years, you've got to be a half glass full kind of guy, and you've got to look for the positives. And of course, it's always the people that you meet on the ground—the frontline workers who are absolutely dedicated to their families, the mothers and fathers that will go to heroic lengths to get their child vaccinated, or get their child fed, or get their child educated.

People just like you and me, who are caught up in extraordinary circumstances and doing heroic things to serve their families and serve their communities—that's the thing that keeps you motivated. Of course, it's discouraging dealing with the political masters and the military masters that are responsible for the decisions that led to these problems.

But it gets a bit cliché to say we have admired the resilience of communities. I can tell you, people in Lebanon, people in Syria and so on, they're sick and tired of being congratulated for their resilience. They just want the conflict to end. They want conflict to end. They want the chance, just like any of us, to bring up their families in peace. You know—empathizing and feeling an enormous sense of solidarity with those people once the political leaders finally make the right decisions in having a lot of hope in these countries eventually emerging.

Dr. Morrison: Thank you, Rick. And thanks for all the work you do, we're really indebted to you and to your colleagues. It's so impressive and you've left on a positive note. I hope we can stay in touch. And as we move into 2022, and as we reach the next stage, we'll want to re-engage and, and talk further, but thank you so much. And congratulations on the gains you've put in place.

Dr. Brennan: And, I will. Thank you. Thank you for your gracious words. We always say the work we do, we feel absolutely privileged. This is privileged work. So, thanks for your interest. Thanks for your support.

Dr. Morrison: Coronavirus crisis update is produced by Liz Polver. You can find our full catalog of podcasts, including Pandemic Planet on our homepage at CSIS.org/podcasts.