This is a conversation about data. How we use and misuse it. How we often make decisions without it. What you do when you don’t have data but need to make a decision. It is also a conversation about standards and whether they make us less brave.
Transcript
Before we begin, I'd like to say a big thank you to all of you who have provided feedback to the first episodes. Trumanitarian is very much an experiment. And I think the only way to get it right is if there's a really solid feedback loop from all of you who listen in, so that we know where to take the show. So please keep your comments coming. We appreciate the encouragement and the stuff you like. But we also really listen to the criticism and the stuff that you think we can do better. So send us your comments, you can reach us on email info@trinitarian.org, or on Twitter at the handle @trumanitarian. Or you can leave a message on our Facebook page, or on the LinkedIn page we have set up. We had planned to put out an episode today on crowdsourcing and tech and the role it can play in decision making in certain onset disasters, but we had to postpone the recording of that interview. We hope to share that with you very soon. So instead, I'd like to share with you part of a conversation I had with Siri Melchior Tellier. Siri has a background in public health and demography and worked for many years with the UN, with UNFPA, WHO and a number of other agencies. In the early 199Os, Siri returned to Denmark and became head of international for Danish Red Cross and that's where I first met her. She claims to be retired, but you can't see it if you don't know it. She continues to teach at Copenhagen University, she does research. And she very often metals in the Danish public debate on issues around development, humanitarian aid, and demography. We come into the conversation at a point where we have spent a lot of time discussing partnership trust, how to work in development situations, how that's different from working in humanitarian situations. And we're touching upon the Nexus before we quickly move on to standards, and then information and decision making. Please enjoy the conversation.
These days. We call it the Nexus
Siri Melchior Tellier:Yeah, I think we call it something like that before it's been there for...
Lars Peter Nissen:[inaudible]... development. I mean, it... there's a lot of different concepts that essentially say the same things. How do you get these two systems to operate seamlessly?
Siri Melchior Tellier:Yeah.
Lars Peter Nissen:Now have we gotten better at it?
Siri Melchior Tellier:I think we have gotten better in some ways, in many ways, actually. I think... [sighs] I think for example, when I started working with the Red Cross, that was in nineteen ninety-two, we had no standards, or we as a field had few standards. You would have the Rwanda crisis in nineteen ninety-four and people came out and had wildly different standards for what they should do. That makes it much more difficult for the local government, or the local society, to take it over when you leave. And hopefully you do leave. And so if you have one pump that's one kind and another pump, which is a different kind (I was working a lot with pumps in those days), yeah, it's very difficult for the local population to know how to fix them. That's a developmental issue also, but in a humanitarian situation, you're installing all this stuff. And then you're leaving behind the mess, because you're teaching people who will not be able to get... let me give you an example, I think it was Myanmar (was it Myanmar? Was it Cambodia? It was Cambodia)... where one of the assessments was that all these donors had trained 20, 30, 40 different medical categories, none of which were compatible with the local definition of what a doctor should do, or what a nurse should do or whatever else. They had no... they couldn't be integrated afterwards. What a shame! But you don't have time! Theres this internal fight against time, which I think is very interesting. We learn to cut corners. Anyway, you asked whether it got better. So I think we got better at the standards. I think we really got a lot better on that. You know, everybody's citing some of these inter-agencies committee standards, or the SPHERE standards. Everybody's citing these. That's nice. I like it [laughing]. Not that you can always live up to it. Some of them are stupid but at least you... not realistic. But at least you know, more or less, what you can disagree with. And, yeah, so that's a good thing. People... I think, in general, you don't have quite as many people who have never been outside Denmark who suddenly arrive in Rwanda and are supposed to look after a refugee camp, you know. I mean... no, you don't have that so much anymore, so much. Coordination... now we may disagree on this a little bit. I think we've gotten better. At least you have meetings, but of course, I mean, meetings is a horrible word. But of course, a meeting can just be a waste of time. I think they figured out in Mozambique that they spent 40% of their efforts on coordination. Something like that. I mean... you know, instead of getting... and we still don't have (and this really upsets me, because I am data obsessed) is, you know, when you have 40, 50 different health surveys in Haiti, by different organisations with different definitions, so you cannot get a sip-... you know, you're wasting time and you're not getting a normal picture out of it. Just to be able to show, with your own log-... t-shirt on TV, that you have the data. This is horrible part of it.
Lars Peter Nissen:Yeah. Just to get back to you on the coordination side.
Siri Melchior Tellier:Yes. Sorry. Yes.
Lars Peter Nissen:So I don't disagree that we've gotten better. I think my issue is...
Siri Melchior Tellier:Right, cause it was so bad.
Lars Peter Nissen:There's that. But there's also that we have somehow detached the exercise of coordination from the benefit.
Siri Melchior Tellier:Yeah yeah yeah yeah. It's sterile.
Lars Peter Nissen:So what's the return on investment? What's what what is the optimal level of duplication? If you spent $10 million coordinating, you can duplicate distribution for $9 million to get a better outcome.
Siri Melchior Tellier:Yeah, absolutely. Cost Benefit. Yeah. Yes.
Lars Peter Nissen:And that's, I think, is where my issue lies. And I probably tend to think that, that we need to replace coordination and... sorry, we need to replace coordination with collaboration as the central operating principles. But that is a very long story and I'd love to talk data with you.
Siri Melchior Tellier:[laughing] Yeah.
Lars Peter Nissen:So should we jump into the data discussion?
Siri Melchior Tellier:Sure.
Lars Peter Nissen:I mean, so in humanitarian situation, you're under time pressure, you often have no clue what's going on, and still, you have to make decisions. So talk a bit around your your your take on dat, decision making support...
Siri Melchior Tellier:Yeah. Okay. I think I'd like to start out with some quotes from other people with which I totally agree. One of them is (I've heard it from Gilbert Burnham from Johns Hopkins, I don't know whether he made it up)... 'But he says public health is about making decisions on incomplete information.' And that is, of course, especially so in a humanitarian situation. But let's face it, that's the rest of life too. You're always making decisions on incomplete information. It's just that in the humanitarian situation, things are changing so quickly, and you don't have time to gather all those data. So I mean, how do you find some really smart data and not just collect data? And so then I want to quote what I believe is somebody called... which is called Garfield... What's his first name?
Lars Peter Nissen:Doctor Richard Garfield.
Siri Melchior Tellier:And you also quote that in ACAPS. And that is, number one, know what you want to know, number two, makes sense, not data, and number three, it's better to be approximately right than precisely wrong. I love those. Because people gather data on things that really are not useful and what they often do is to say, Oh, we have this situation, everything is new, we have to go and gather data everywhere. You don't have to. You should be brave enough to collect data all the way from the Afghanistan the white beard he knows a lot of stuff, you... the taxi driver, the driver, always knows a lot of stuff. as well as walking around and seeing things, and what you can get online, and what you know the standards are from whatever... And you don't even have to necessarily always look it up and sphere, you should have some things in your cortex of what you can expect. Otherwise, why do you go to university if you don't expect anything? And so I think it's... you know, that thing of making sense, not data, not more data. Because if you want really statistically significant stuff, it'll take you three years and take... cost $3 million. And then the last one, be approximately right rather than precisely wrong. You're always operating within uncertainties so exactly as you were saying before, cost benefit of making it even more precise... For somebody like me, who is sort of swayed by statistical thinking, that doesn't matter. I mean, yeah, you don't have to have it precise. It doesn't have to be confidence level of this and that.
Lars Peter Nissen:You use the word brave.
Siri Melchior Tellier:Yeah.
Lars Peter Nissen:Have we become less brave as a community?
Siri Melchior Tellier:Probably. I mean, Bravery is... to my mind is having the courage to... maybe that's what comes when you standardise everything. Then you think, okay, I go according to the standards, otherwise, I get fired. So you don't have to think. Maybe that's part of it. Yeah, I think that might be part of it, that you don't have to think yourself because it's already there. That's a very dangerous, in general in life and especially humanitarian situations... I mean, I've been working on and off with humanitarians... full-time job for 10 years, when I was director of Red Cross International, but... International Red Cross and Danish Red Cross. But yeah, I think... Yeah, I think... not sure. And I don't think anybody's come up with something I really think this is really what it is. But I think when you do have all the standards and coordination, maybe you say, Okay, I'll just do what everybody else is saying. Not rock the boat.
Lars Peter Nissen:So standards make us less brave.
Siri Melchior Tellier:Depends on what kind of person you are, I think. I think standards make me more brave. Because if I agree with them (I often disagree, you know)... but I mean, if you... again, if you go something like Human Rights standards, or Humanitarian Law standards, you are a much stronger person coming into somewhere. You feel... your shoulders are down, because you know what is... what you're thinking is something that has been signed by the whole world... all the countries of the world almost. So you think, this is not just me, Siri, saying this, this is something where I know that we should have some of... make... it's a great difference. Huge difference. And that one, I think is good bravery, good courage. But of course, you also have to have the courage of saying, right now... Not human rights, don't worry, I'm not [laughing]... (Yeah, sometimes human rights, you can't necessarily get through to 100%, but you can say you could get 30%, whatever it is)... But I mean, you also have to have the courage to certainly understand is that our technical standards and say, Look, maybe we won't be able to provide 15 litres of water, maybe we can do with less, and just the first weeks, but as long as we know we're working towards something or other, and that other people are also working toward that, that's where coordination should come in. That you're not working toward different standards. That's what went wrong in Rwanda, when everybody's working on different standards. And then what do you what do you do with the population when you leave? Does that make sense?
Lars Peter Nissen:Yeah, very much so.
Siri Melchior Tellier:So I mean, one of the things... So I believe those four principles I mentioned before by Gilbert Burnham and by...
Lars Peter Nissen:Richard Garfield
Siri Melchior Tellier:... Richard Garfield, yes. And all of them actually require you to think. You don't just go to the SPHERE handbook and says it says that 3% of the population will be such and such. Yes, you go to that, but you also try to think yourself.
Lars Peter Nissen:You know, the difference between a roundabout and traffic lights?
Siri Melchior Tellier:No, tell me.
Lars Peter Nissen:Roundabouts a safer than traffic lights. But most people prefer traffic lights. Because it's clear when you go and when you don't go. So you know what I mean? Whereas when you have a roundabout, you have to be aware of the other traffic and you have to have a much stronger situational awareness. And I sometimes think that the problem we have is that we... it's so nice that it's red or green to know where to go or not. And then we stopped thinking about the other players. And actually, we end up with a system that is less safe. And especially because we work in very messy situations.
Siri Melchior Tellier:Yeah, you need something that you can hold on to. Because you're going to make... you are... I mean, when I teach this... when I've been teaching this course on health and emergency for 10 years, and one of the words we use all the time is dilemmas... There is no answer. It's something where you have to make a decision. It's not... Yeah, it's dilemmas. You may not have an answer, an easy one, red or green.
Lars Peter Nissen:So how do you institutionalise that? Because I think the problem is that we we obviously don't want operations like Rwanda, which was a disgrace.
Siri Melchior Tellier:Yeah. And everybody... it's a good standard we have of what not to do.
Lars Peter Nissen:Yes. But if we then lose the sen-... the practicality or the sensibility of how to apply these standards...
Siri Melchior Tellier:Yeah, how do you do that?
Lars Peter Nissen:How do you institutionalize that?
Siri Melchior Tellier:I don't know. I don't know. What I think works well, is to have a learning... thinking... a learning atmosphere in the office. That's very difficult if you're in a hurry. But what I find very interesting, and I've found it works, is that every time you've done a major thing in your group, then you just have... instead of doing an evaluation (yes, evaluations are also great)... but instead of doing that, to have it built into your daily work, so that you sit maybe once a week and say, 'What went right and what went wrong?' And you, if you're the boss, you start out by saying what you yourself think you did wrong. Or you could do better next time. It's not right or wrong, but you know, things we thought 'hmm... maybe this...' Then it becomes okay to talk about what's good and what's bad, without saying, 'Ah! You're to blame!' Sometimes what I've done (but that's only helpful if you have a wall, you don't always have a wall)... but I put some of the problems up on the wall. And then... so that people sit there and look at them and say... for example, if you have an auditor report, and they say, you know, you don't have backups, so you don't... some of it's very innocent and some of this is not so innocent. That's what I did sometimes in my office in North Korea. And we put this on the wall. And then every time we had a meeting, we would look at them and say, Have we progressed on it? Then it externalises the problem. It's not your problem, it's something we have together. Now, I don't know whether this... to my mind, that helps you become willing to face things that you could have done better, without feeling that you have to go and whip yourself.
Lars Peter Nissen:So maybe what it boils down to is accountability.
Siri Melchior Tellier:Yes, I think that's at least a very large part of it. Now, I'm all in favour of, you know... Are you for or against? I'm for accountability. But it's just how it's done or to whom. And it's nothing new, i'm saying, it's just so difficult to implement. I mean, this is not because stupid... people are stupid or nasty. It's difficult. For example... Let me give you an example. So during some of these food crises in North Korea, I was also there for some of it. And we would have, in the central medical store of the government, there would be 10, 20 different rub halls with medicines in them from each of the different agencies (from Red Cross, from UNICEF, from everybody else, and God helped me, I also made one for UNFPA.) So we had all these rub halls, and each of them had their own truck bring stuff out. And there was no coordination because the government didn't have any clue what was in them. Now, you can... Most countries, you don't agree on everything with the government. But each of these rub halls, why were they there? Were they... Why couldn't they just get together? Well, I mean... and train people locally to look after them. It's great job to look after rub halls. It's very interesting. So why is it don't because they were all accountable to their own donors. They had to account for how many, you know, maternity kits they had brought out and it couldn't be that somebody else was accountable for them. No, they had to have their own truck where they could take off with... and so it's partially also the accountability to donors. And of course, also accountability to the public. You have to be able to get on TV with your T-shirt that says UNFPA. (And nobody tells you to do that. But that's how you get money. If you get on TV with your own t shirt. And then people say, Oh, these people know, they have the data they must know.)
Lars Peter Nissen:And so the interesting thing about what you just said is that we know this. And we know this fully, and we don't we've seen it for decades, right?
Siri Melchior Tellier:Yes. I mean, people in humanitarian business, basically want to do... to make the world better. Like I have that idealism. Basically, I think that idealism is there for most people. Yes, there are also many other things, there's the perks, there's this and that, but I think most of them at some level, most people in the world if not... (maybe not everyone. I sometimes mistake things)... but I think most of them working in the humanitarian actually would like to make the world better.
Lars Peter Nissen:Yeah, I agree with that. And so I think the really interesting question is, you... We started this conversation talking about idealism, and clearly, you're driven by that. You told me that the years haven't chipped away at you yet. Why not? Why... you're there in North Korea, you put up your own rub hall, you're part of the problem. Doesn't chip away at your idealism?
Siri Melchior Tellier:Well, I guess maybe I'm just the person I am. I mean, I don't... I think there are different kinds of... I just have an eternal positive attitude. I can't help it. I was born with it. But it's also because, despite all of this, you can see there's progress. Of course there's progress. I mean, the maternity kits we provided in North Korea, of course they made a difference. They have very... you have to recognise the strength of each country, also. I don't know whether I'm allowed to talk about this, but actually North Korea, they have very educated people, and they have very educated professionals. And I remember once walking with one of my Korean colleagues (we were visiting... just sort of stopping the Jeep because there was a temple we wanted to walk around) and some guy who was looking after the sample came over and said, 'What's this foreigner doing?' That's what I was told. And then the... my colleague explained, 'We're here because we want to help the maternal mortality'. And the man was so happy. He smiled, and he, you know, said 'Thank you, thank you, thank you.' He wants to do that, too. I mean, there's this motivation that you can find in your colleagues and normal people in the country and you can actually help to improve on. And we did. The maternal mortality improved. And you can have all kinds of discussions with people on the way and say, but what about this guide? Or what about that guide? And how did it work? Yes. And you can help them actually have the accountability, a sensible accountability, and let them get interested in making things better. Because you can show them... not show them they know. But I mean, you can be, as again, the sort of the stepping stone. You can be the one who's helping them to access new information. You are their window on the world.
Lars Peter Nissen:And so with your public health background, as we as we speak, we're in the middle of one of the biggest global crisis we've ever seen. What do you see?
Siri Melchior Tellier:Well, I think it's very interesting, because I was telling the head of our department... I was saying, Look, we just have to tape the whole thing, and then replay it in August, we don't have to teach anymore. Because people are learning all kinds of concepts that, you know, I couldn't... you know, I spent hours trying to teach the thought of herd immunity, or what is called an English reproduction number (That is, how quickly you you pass it on to others.) Those things it was... you know, I really had to struggle to get people to understand it. And now everybody knows. And one of the most important things, I think, I hope, at least some people have taken on board is that we don't know everything. And that we have to be... as Gilbert Bernard says, We have to be humble enough to say we don't know everything. And on the other hand, we have to be brave enough to do something. I think that's very wise, saying. And I think that COVID-19 is teaching people that we don't know, very much actually. We're learning all the time.
Lars Peter Nissen:Yeah, it really does test our tolerance for ambiguity, I think
Siri Melchior Tellier:Yes. And different countries are doing it so differently. And what is the leaders say? Do they talk about we or do they talk about I and they? You know, it's all this... How do you approach public health? I think it's very interesting.
Lars Peter Nissen:What are the implications for the humanitarian sector?
Siri Melchior Tellier:Yeah, a lot of people have talked about that. I don't know. I think one of the things some journalist asked me is some of the... it's... I think it's two way learning. One of the most important things, I think, is this ethical principle of triage where (I was talking about with journalists who said, What can we learn from the humanitarian sector?)... And I said, one of the most scary parts of humanitarian ethics is triage, where if you have... the difference usually is between mass casualty... and multiple casualty and mass casualty. Mass casualty... multiple casualty, sorry, is when you have... you're stretched, but you can still manage. And you can still treat those are most sick first. Versus mass casualty where you have... it's overwhelmed.
Lars Peter Nissen:You run out of ambulances.
Siri Melchior Tellier:You run out of ambulances or beds or whatever it is, and you then start treating those who are most likely to survive. So the scary thing we've had in several countries, I won't mention names, where they say, we're not going to treat people over 60. And it may be a humanitarian principle you're living up to. That's pretty scary. And I mean, the question is also, When you decide that? You know, if you're really overwhelmed, maybe that's what happens. If you're not that overwhelmed, Is that little bit too early to put that principle into place? So it's timing, also. And context. You're nodding. I mean, it's scary.
Lars Peter Nissen:Well, I think that... We talked about empathy and I think the fact that we have become, quote unquote, the victims of this may enhance our empathy.
Siri Melchior Tellier:Yes, yes, yes, absolutely.
Lars Peter Nissen:I also think it reshapes our understanding of how physically we work together. You know, I do think it will disrupt the way we work in a number of ways. The thing that stands out to me is how we handle ambiguity. And I think where we go wrong is we always want to put it in a box.
Siri Melchior Tellier:Yes, that's exactly what I mean, also, that, you know, we don't know everything. We don't know what the situation is and how to handle it. And I think it's very dangerous to say, we know everything, and we are doing it the right way. I don't think we know yet. And I really, really hope, because I think it is a very healthy thing, for people to know that we don't know everything and that we do have dilemmas and ambiguity, as you say. I'm hoping that will stay.
Lars Peter Nissen:Yeah, I just want to... I think the I think there are two different aspects to the ambiguity. On one side, we actually don't know what things mean. We don't know a lot about the disease. Yeah. And on the other hand, we don't have good data, right? So we don't know what the dashboard is telling us. And we don't know whether the speed is correct.
Siri Melchior Tellier:And, of course, if you've gone to university, you know that viruses usually behave in such in such a way, but at this point, we really don't know, for example... the big thing is immunity. We don't know how much and how quickly I know that all kinds of things. And, you know, without that, it's very difficult to decide on the strategy.
Lars Peter Nissen:And so what it really has done for me is... my thinking is around humanitarian action as a narrative, right? How do you shape the narrative? What's the story of COVID-19? We just don't know. We have a whole bunch of assumptions around, 'Oh Africa is going to be really badly affected. Maybe it is, maybe it isn't. Latin America, right now, is really badly affected' Why is that? Why is it... Is it because we don't measure it in certain African countries? Is it because... We just don't know.
Siri Melchior Tellier:And I think the most scary part of it (and scary being because dilemmas are scary) is, you know, are we... some people say... In the beginning, I had some empa-... or sympathy for thinking, let's just develop the herd immunity, and some people will die. But maybe some in the whole thought that you have to weigh the economic impact, because economic impact has health impact. So you may have more people dying from economic impact than from Corona, or COVID. And so I'm a public health person. Of course, I want to save lives. And I also see the impact of if you don't do it, and if it really gets... And the long term effects... I mean, so many things we don't know. But it's that basic dilemma which I think is so interesting when different countries are approaching it differently. And I don't think we know the answer yet.
Lars Peter Nissen:No, but it's also clear that probably it was right to be quite cautious in the beginning because of the high levels of ambiguity.
Siri Melchior Tellier:Yes, absolutely. And that's... Not to quote anybody, but actually the Danish Prime Minister said that, 'You know, we don't know everything, we will make mistakes.' I thought that was a good starting point. And she says, also, 'The worst thing we could do is to wait.' Yes, I totally agree with that. I'm just also, you know... obviously the whole world is in a crisis. But we hopefully will know more, so that we can slowly creep out of it.
Lars Peter Nissen:Maybe a last question for you. Would you still pick the same path with, you know... Would you still go to the same...
Siri Melchior Tellier:Yes. Again, because I think it is, you know, part of a life ideal. But also because it is eternally interesting. It keeps your brain going 24 hours a day. No, not quite. But, yeah, whatever [laughing]. And because you learn so much. I mean, the same things that I was saying before. You learn a lot about yourself, you learn a lot about other people. And I think... And you deal with people and their motivations. Yeah, I don't see how it could be better.
Lars Peter Nissen:Thank you very much.
Siri Melchior Tellier:[laughing] Thank you.