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Opinion and debate: See No Fogeys. Hear No Fogeys. Help No Fogeys?Please note: Views expressed in this section are those of the author(s) alone and do NOT reflect the official position of Médecins Sans Frontières/Doctors Without Borders (MSF).
By Marc DuBois
General Director of Médecins Sans Frontières/Doctors Without Borders (MSF) UK
Ten years ago I visited our projects in Pool Province in Congo-Brazzaville. It was during Pasteur Ntumi’s armed, mystical insurrection; a time when military groups chose videogame names like the 'Cobras' or 'Ninjas'. I heard more than once that Ntumi could levitate. But that is a different story.
We lurched down the ersatz road, passing many villages. They looked quiet. They looked abandoned. Empty, I kept being told. Empty. But they were not empty. Everyone under 45 had long bolted for the IDP camps, but the elderly hadn’t left. Occasionally I would see a skinny man, somewhat dishevelled and gray, carrying a bundle of wood or wandering the dusty alleys between houses.
If terms of vulnerability, those community guardians must have registered off the charts. And we weren’t touching them. We were driving by without seeing them, or seeing their absence in our busy health clinics.
Neglecting the elderly
It shouldn’t be that way. Impartiality dictates to humanitarians that we make decisions based solely on the needs of people, not their life expectancy after treatment or value to society. Attaching value to human life is inimical to humanitarian action. Ditto for medical ethics.
We don’t value people based on age. Grannies are absolutely equal in value to toddlers. We don’t try to justify differentiation by arguing cost effectiveness in terms of life value. That kind of thinking will lead you down the path to hell, to saving the owner of the factory over the workers, the teacher over the vagrant, the NGO expat over the NGO local staff.
Impartiality implies that you have done a proper assessment to identify, in this population and in this crisis, those most in need. In a place where the needs overwhelm resources, it implies choices will be made. As the research shows, though, we don’t do a good enough job of assessing needs when it comes to the elderly.
The problem is not one of mere choices, but of the underlying subconscious preferences; of blinkers. Some of these blind-spots have evolved within our work. For example, we use shorthands to target people/areas of greatest need: “under fives,” “IDPs,” “pregnant and lactating women” are typical proxy indicators of greatest need. And with good reason.
It is true that you will find higher burdens of needs among these target groups, or overlapping needs (e.g., sick child plus no shelter or clean water), or greater severity of needs (e.g., on average, a toddler with malaria is more at risk than an adult with malaria). But has looking for proxies meant not seeing others?
The way our brains work, it seems that if you are focused on one thing you will not see something else. (Here is a great test of selective attention.) The elderly have different needs from those of children, and you need to look in a different way.
For example, as a starting place, you need to make sure that your assessment tools are able to ‘see’ elderly people. Much of MSF data collection puts people into boxes: < 6 months, 6 months to five years, 5 - 14 years, and > 14 years. We literally lump teenagers in with octogenarians. Where else would that happen except in wedding photos?
With data like that – with the conceptualisation of our target population underlying those numbers – busy teams miss those who do not arrive. That gap in spite of understanding that elderly have special access issues. It’s sometimes really simple. If you’re sick and seventy, trekking 10 km to find healthcare is not ideal.
Research leads to calls for paying attention; for systematic consideration of the elderly in humanitarian response. But why are the decks stacked against impartiality in the first place? One reason is the way we think about children in our own societies, and in particular the way we think about their well-being.
There’s a certain tragic disposability of children in places where birth and mortality rates are high. And in the West, a tragic overvaluation, with children raised in porcelain towers. (See my blog on baby helmets). Apologies, this is the slippery turf of sweeping cultural generalisation, but you get what I mean.
In the end, it is not accidental that the humanitarian project prioritises children. What is the UNICEF equivalent for the elderly? There is none. Why is Save the Children so much larger than HelpAge?
The quantity of Western NGO resources essentially devoted to children in other parts of the world reflects a very Western valuation of children. That institutionalization of our value system produces a certain set of programme activities, the organisations that deliver them and, ultimately, that thing we call the humanitarian system.
Inherent in those values is the feminisation and infantilisation of victimhood. Powerlessness plus victimhood equates innocence, and that underpins why people give money to a cause. You can sell starving babies – we do it all the time. Try geriatrising it. Pause the camera on the face of an old man. You won’t run a billion-per-year NGO on that face.