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Prof Mike Clarke, Director of the All-Ireland Hub for Trials Methodology Research at the Centre for Public Health in Queen’s University Belfast, is a founder of the Evidence Aid initiative, which was launched in 2004 after the devastating Indian Ocean tsunami.
Evidence Aid works closely with organisations like the World Health Organisation (WHO), the US Centres for Disease Control and Prevention, the Centre for Global Health at Trinity College Dublin, and a number of NGOs to provide the best evidence on the effects of different medical interventions before, during and after disasters, Prof Clarke told the Medical Independent (MI).
Prof Clarke, former Director of the UK Cochrane Centre, recalled how he came up with the initiative in the wake of the Indian Ocean disaster, which hit on December 26, 2004, killing over a quarter of a million people in 14 countries.
Prof Mike Clarke
Measured in lives lost, it was one of the world’s 10 worst earthquakes and the single worst tsunami in history. A great deal of humanitarian aid was needed because of infrastructure damage, shortages of food and water, and economic damage.
Epidemics were of special concern due to the high population density and tropical climate of the affected areas. The main focus of humanitarian and government agencies was to provide sanitation facilities and fresh drinking water to contain the spread of diseases such as cholera, diphtheria, dysentery, typhoid and hepatitis A and B.
“At that time I was involved in the Cochrane Collaboration, which brings together research evidence on health and social care,” Prof Clarke recalled. “I had a sense immediately that the tsunami was devastating and I wondered what researchers were doing to help. It was a sense of ‘is there a body of research out there that could help people making decisions and if there is, why aren’t we, in this global organisation that’s attempting to bring together research evidence in healthcare, doing something about it?’”
In the days that followed, he talked with colleagues in Australia, Thailand and India about what could be done, not just to help those hit by the immediate disaster, but also how to be better prepared for a similar crisis in the future.
“That’s what kicked it off and it was then a case of working with people in the humanitarian disaster sector to see what questions they might need answered and seeing if there were answers. We found that there actually weren’t a lot of answers from research and what we needed to do was to get more systematic reviews in which the evidence was brought together in an unbiased way and then start making those reviews available in a one-stop shop.”
Certainly, Evidence Aid is meeting a need. Since it was established in 2004, nearly 1.6 billion people have been affected by disasters globally, with the estimated total cost of over one trillion dollars.
Despite this, robust evidence of the effects of interventions in humanitarian responses is hard to find, even as recognition of the need for evidence-based decision-making is increasing.
The aid sector is seeking to improve the effectiveness of its response to disasters and demonstrate ‘value for money’ and recognises that to do so, it needs to know what does and does not work. There is a vital need, therefore, for a more evidence-based approach to humanitarian action.
But hunting for the evidence often means sifting through information in tens of thousands of reports spread across thousands of journals, books and websites with a wide range of methodologies and sometimes conflicting information. Clearly, aid organisations and medical professionals need better access to high-quality collections of the evidence, highlighting its relevance to them. That’s where Evidence Aid comes in.
It provides access to more than 160 systematic reviews and documents for those working in disasters who are planning response, recovery and rehabilitation. The aim is to make it easier for such responders who need the evidence and don’t have time to browse through multiple documents and distill them before making their decisions.
Apart from advocating a more evidence-based approach to humanitarian action, Evidence Aid also provides reviews and collections of evidence on current issues, like the health of refugees and asylum seekers in Europe.
“There’s the basic health-type material, how you manage people with fractures and how you manage people with broken legs and burns and so on. But we were asking, is there research out there and is there a way that you can bring it all together? Questions like, should you be giving people antibiotics before they have surgery to reduce infection? — mental health issues and post-traumatic stress disorder, grieving, whatever evidence is out there and presenting it in a way that is not telling the responders what to do, but is saying ‘this is what we‘ve been able to find about the effects of these interventions that you can incorporate into your decision-making and your thinking’,” Prof Clarke explained.
“Something may be effective but it may be too expensive, it may not be available on the ground and may not be feasible in the disaster context. If it’s effective in a hospital in Dublin, for example, it doesn’t mean it’s going to be effective in a field hospital. But, equally, if it’s ineffective in a hospital in Dublin, why would we be doing it in a field hospital in Haiti?”
The core aim of Evidence Aid, Prof Clarke stressed, is to help aid workers and medical professionals to be able to make informed choices. “I don’t particularly care whether or not they follow the evidence because they have other things to take into account. My evidence might show, for example, that a drug works in treating somebody who has had a heart attack, but maybe the person who has had the heart attack doesn’t like the side-effect profile of that drug and would prefer a slightly different drug.
“We’re trying to offer the evidence on effects primarily, but we’re also trying to say we have brought together global evidence. We’re not cherry-picking anything. We’re not coming in and waving one study at you. We’re saying there have been seven studies on this topic and this is what they all say.
“We’re trying to be a repository where people can come and get answers in terms of disasters and illnesses. We can say ‘there’s a body of research that’s looked at that and there is another body of research that looks at interventions and strategies that you might adopt to alleviate the problems’. It’s all here in one place and it’s all free, either because that’s the way it’s been published or we’ve talked with the publishers and they’ve made the material available. That was an early principle after the tsunami. We believed nobody should be paying for access to this information at a time like this.”
The main benefit of Evidence Aid comes in the planning stage ahead of the next inevitable disaster, Prof Clarke contended. “When a disaster strikes, no-one is really going to look at the literature thinking ‘what am I going to do?’ We know though that when Typhoon Haiyan hit the Philippines a few years ago and we bundled together what we could find, responding teams that were going out there were looking at that document on the way out.
“I don’t expect a surgeon to look to Evidence Aid when someone is queuing up outside the field hospital. What we would like to see is that the surgeon was able to study the guidelines in a quiet, calm atmosphere before a disaster strikes because we always know there is another disaster coming. We’re overdue a big earthquake, for example. We had the recent one in Italy. We had the Haiti quake in 2010 and Japan in 2011.”
In fact the disastrous earthquake in Haiti in 2010 saw the coming of age of Evidence Aid, when people turned to it in a major way. “We’ve almost gone through three five-year phases,” Prof Clarke commented. “After the 2004 tsunami, we started putting material together on the website (www.evidenceaid.org) and then Haiti happened in 2010. So we bundled up a whole lot of material on fracture site management and sent it to the WHO and it was shared with those in Haiti.”
Prof Clarke and his team subsequently secured some funding for the initiative and were able to appoint a co-ordinator. “Then last year we got a grant that allowed us to appoint a Director. We’re not doing the research; that’s expensive. What we’re doing is funding the research that others have done and compiling it and we’re also encouraging others to do the research.
“We now have funds for two years. It’s nowhere near what’s needed but we have a full-time Director, an Operations Manager and a part-time Secretary. Our Director is in frequent touch with organisations like the WHO, Oxfam, Médecins Sans Frontières (MSF) and US Aid to discuss their needs and how we might work together in meeting those needs.
“We are in frequent contact with about 30 of the world’s major NGOs and major responders and donors and actively discussing what their evidence needs are and who is going to fund the research that might be needed. We are co-ordinating some of that and encouraging it and reminding them that they need to think about evidence needs.”
In healthcare now, everybody thinks about evidence-based medicine, Prof Clarke emphasised, and he believes it should be no different when it comes to the humanitarian sector.
“If you go to your GP, that GP is using the best evidence to make a diagnosis and there’s no reason it should be any different in the humanitarian sector. If anything, it should be even more stringent in that sector because people in a disaster have been injured and are particularly vulnerable. So we should be working even harder to say what we are doing has been shown to be effective. We’re not going to do something that doesn’t work.
“Donors and funders are beginning to see that as well and are turning to aid agencies and saying, ‘how do we know the money we’re giving you is going to be spent on good things? You’ve asked to buy this equipment but how do you know this equipment is going to be beneficial? What’s the evidence for that?’
“I’m not here to tell the doctors or the patients what to do, I’m here to give them the evidence and their job is to consider the evidence. My job is to make it as reliable as possible and that’s what we’re trying to bring to the humanitarian sector. We are very much part of the movement that says we have to be more evidence-based.
“In a disaster, people want to help and we say, ‘yes, but you want to make sure your help is going to do more good than harm’. Our website doesn’t have all the answers but we can offer the research done to date that can help you. But don’t go looking yourself for anything further because someone has looked really hard and found nothing.
“Or, conversely, this is the evidence to date. Put it on the table and discuss it at your meeting because the most robust evidence should be winning the argument on what works and what doesn’t work. No-one should be going into these meetings and saying ‘well, it works and when I did it, it was fantastic’. They should be saying ‘it works because there’s a body of research out there that is good-quality research showing that it works’.”
Dr Dónal O’Mathuna, Senior Lecturer in Ethics, Decision-Making and Evidence at Dublin City University, put it this way when he addressed the subject recently: “Well-intentioned humanitarian interventions have been criticised when their outcomes are not beneficial or they have unintended adverse effects. An evidence-based approach is an important way to improve the chance that interventions and policies are effective and safe. Evidence-based approaches help in accurately identifying the needs of those to be helped.”
Dr Dónal O’Mathuna
Evidence Aid is also conscious of the need for humanitarian workers and health professionals to glean any lessons from a disaster that would help with the next crisis. The West African Ebola virus epidemic from 2013 to 2016 was a case in point.
“How can we be confident,” Prof Clarke asked after the outbreak, “that the care we provide for patients and practitioners in the next disease outbreak is effective?
“Whether we’re interested in vaccines, rehydration strategies, protective clothing, coping with bereavement or any of the numerous dilemmas that will arise, reliable and robust evidence is vital to ensure our best intentions lead to the best outcomes.”
Isolated cases of Ebola occurred in the UK and cases in the US and Spain led to secondary infections of medical workers.
By May this year, the WHO and governments in the countries affected had reported a total of 28,657 suspected cases and 11,325 deaths.
So, how might Evidence Aid help the world to prepare for another outbreak of Ebola or other diseases?
“We need to ensure that people have access to the evidence that has already been generated and ideally in the form of systematic reviews,” Prof Clarke says. “Once we have determined the key areas of uncertainty, we need to be ready with the randomised trials that could resolve these areas of uncertainty. Our aim is to ensure that best intentions deliver the best outcomes.”
See www.evidenceaid.org for more information.